M104 T1 L11 Flashcards
Under what circumstances might it not be a good idea to administer food orally?
when it is unsafe to swallow
when there is a damaged / non-functioning gut
when the patient is unable to eat enough despite oral nutrition supplements
What are enteral routes of nutrition support?
nutritionally complete liquid feeds through various tubes which access the gut
When are enteral routes of nutrition support used?
if the gut is functioning
if the patient is unable to swallow (might be unconscious)
if the patient has insufficient oral intake despite supplements
if the patient is unable to tolerate supplements
if it’s the patient’s choice
What are par-enteral routes of nutrition support?
Nutritionally complete liquid feed which is broken down into glucose, amacs, fats & engineered to be safely administered IV
When are oar-enteral routes of nutrition support used?
if the gut is not functioning
if the patient is aperistaltic
if the gut is obstructed
if the gut is too short (most always when less than 100cm of small bowel remaining)
if the gut is too damaged or inaccessible
High fistula
What types of external access are there?
via the stomach, the jejunum
gastric aspiration port
gastric aspiration holes
jejunal administration port
What are the different routes for enteric access?
Nasal, percutaneous
Where might food delivered by enteric access be delivered?
Gastric, jejunal
How is enteric access put in?
Endoscopic vs. interventional radiology
What are the advantages of nasogastric tube feeding?
it is fast and easy to pass the tube
it can be done at the bedside by most nursing staff
it is minimally invasive
it is generally well tolerated
it is easy to remove if not tolerated / no longer required
When is nasogastric tube feeding suitable for use?
if the patient has a working gut if the stomach emptyies (into duodenum) when it is safe to put the tube through the nose and down the oesophagus Patient must accept / tolerate the tube for short-term feeding (up to 8 weeks)
What are examples of short-term nasogastric tube feeding?
whilst unconscious on ITU, post-op, post-stroke, acute illness
What are the risks of using a nasogastric tube for feeding?
the tube might become misplaced / displaced / blocked
reflux / aspiration, might not be tolerated
Tube itself or volume of feed infused
How is the correct placement of nasogastric feeding tubes confirmed?
a CXR from theupper oesophagus to below the diaphragm
The NG tube should remainin the midline down to the level of the diaphragm
The NG tube shouldbisect the carina (T4)
The tip of the NG tube should be clearly visible and belowthe diaphragm
The tip of the NG tube should be several cm (10) beyond the GOJ to be confident that it’s within the stomach
What are the advantages of of nasogastric feeding tubes?
Minimally invasive (may need x-ray / endoscopy to place it) Less likely to aspirate / get misplaced
What are the risks of nasojejunal feeding?
it is technically difficult
it generally needs endoscopy or placement in interventional radiology which can createa delay in feeding
there is a risk of mis/displacement
it may not be tolerated
What are the advantages of using PEG & RIG for feeding?
Uses the gut / physiological
Durable - tubes last up to a couple of years
Unlikely to be accidentally displaced
No tube in throat / on face - comfort and cosmetic
What is the criteria for using PEG & RIG?
needs a functioning gut
a patient with an inability to swallow adequate food / fluid due to an irreversible or long-lasting cause
a patient who can tolerate an endoscopy and minor surgical procedure
What are the dangers of using PEG & RIG?
can cause perforation (viscous) can cause bleeding, reflux, sepsis Reflux Buried bumper Death (6% at 30 days) Not involved in mealtimes Alteration in body image
What kinds of sepsis is commonly related to the usage of PEG & RIG?
Peritonitis, skin infection
What are risk factors of using PEG & RIG?
has to be attached to a pump 20 hrs / day
misplacement
What causes Buried bumper syndrome?
the internal bumper of a gastrostomy tube erodes into the wall of the stomach
it may become entirely buried within the fistulous tract
What are the advantages of Percutaneous Jejunal access for nutritional feeding?
same advs as PEG & RIG
it is tolerated if there is gastroparesis or duodenal obstruction
it is a longterm option for those requiring NJ feeding
What are the dangers of Percutaneous Jejunal access for nutritional feeding?
same as for PEG & RIG
there is a higher risk of complication due to the position / anatomy of the small bowel
What is used instead of percutaneous jejunal access and PEG / RIG?
PEG-J - has an extension into the jejunum
best of both worlds
What are central access lines otherwise known as?
central venous catheter
central (venous) line
central venous access catheter
What are the dangers of Total parenteral nutrition?
Line “access” complications Misplaced line Extravasation of TPN Clot on the line (thromboembolism) Line infection Hyperglycaemia Fluid / Electrolyte disturbance Over or under-feeding Liver disease atrophy and inflammation of the gut as it is not being used
What are the disadvs of Total parenteral nutrition?
expensive
there are risks / dangers to the procedure
can cause other diseases / conditions
When monitoring Total parenteral nutrition, what is noticed on an hourly basis?
Observations including temperature
Blood glucose levels
When monitoring Total parenteral nutrition, what is noticed on a daily basis?
U&E Mg, Ca, P liver function test full blood count Line inspection Weight
When monitoring Total parenteral nutrition, what is noticed on a monthly basis?
Micronutrients
Triglycerides
What are the two main abbreviations for urea and electrolytes?
U&E and EUC
What are the criteria for refeeding syndrome?
severe electrolyte and fluid shifts
metabolic abnormalities
the patient being malnourished
the patient undergoing refeeding orally, enterally or parenterally
What is the pathogenesis responsible for refeeding syndrome?
E is saved by switching off trans-membrane pumps during starvation
Na (& water) drift intra-cellularly
K & Phos drift extra-cellularly (and are excreted to keep plasma levels stable) = total body depletion
What causes refeeding syndrome?
as soon as the patient gets any E, their trans-membrane pumps are all switched back on immediately
What are the physiological effects of refeeding syndrome?
there is a sudden drop in plasma K and Phos, causes arrhythmias
there is a sudden surge in plasma Na and water, causes overload
How is refeeding syndrome avoided?
Be aware of the risk Check electrolytes (Na, K, Mg, Ca, Phos) Begin replacement before feeding Rule of thumb: start slow and build up As low as 5-10kcal/kg/24hrs Keep monitoring electrolytes daily and replacing as necessary
What are the acute and chronic phases of Wernicke-Korsakoff syndrome?
acute - Wernicke’s encephalopathy
chronic - Korsakoff’s psychosis
What causes Korsakoff’s psychosis?
a late complication of persistent Wernicke encephalopathy - occurs in 80% of untreated patients with Wernicke encephalopathy
What causes Wernicke-Korsakoff syndrome?
acute thiamine deficiency - providing calories in the absence of sufficient reserves of thiamine (by refeeding)
brain damage caused by a lack of vitamin B1
severe alcohol use disorder or absorption issues (malabsorption)
What are symptoms of Wernicke’s encephalopathy?
opthalmoplegia, nystagmus
unsteady gait, confusion
Are the symptoms of Wernicke’s encephalopathy reversible?
yes but only if the patient is quickly given IV thiamine
What are symptoms of Korsakoff’s psychosis?
irreversible memory loss, confabulation, confusion and behavioral changes
What are features of Korsakoff’s psychosis?
has a sudden and dramatic onset
How is Wernicke-Korsakoff syndrome avoided?
Be aware of the risk
Replace thiamine before and during re-feeding
If low risk and able to eat use high dose oral thiamine
If high-risk or not eating then use IV Pabrinex
How long can a medium term nasogastric tube be used for?
10 days - 3 months
In what circumstances can feeding be withdrawn from a patient?
if it requires medical intervention
AND
it is not thought to be providing benefit
What are the advs of using PEG?
Improved life expectancy
Improved QoL - medication can be given vs. symptoms/pain, increase / maintenance of weight, improvement of healing e.g. pressure ulcers
Improved daily activities, increased capacity for rehabilitation
