Malnutrition and Parenteral Feeding

Question 1

What may contribute to malnutrition?

Answer 1

inadequate food intake
disease related

determine using nutritional assessment (diet history) or nutrition screening
anthropometrics (BMI, % weight loss, muscle circumference

Question 2

Parenteral nutrition?

Answer 2

giving nutrients centrally/peripherally where GI tract inaccessible or insufficient GI function
most common site for insertion is via PICC line

• if GI function not working
• if all other enteral routes not working
• <5 days

e.g. pancreatitis 
Ehlers Danlos syndrome
post op gut paralysis
Crohns disease
prolonged obstruction/ileus
prolonged intestinal failure 
oncology patients - BM transplant

Question 3

What is nutritional support?

Answer 3

for people who cant get nutrition from food and drink

Question 4

What is oral nutrition support?

Answer 4

food first approach
fortified diets
more snacks
increase food density with fats

Question 5

Ward based practical strategies?

Answer 5

red tray approach
assistance with feeding/positioning
swallow assessment 
food/fluid charts
manage nausea/vomiting/bowls

Question 6

What are oral nutritional supplements?

Answer 6

on prescription
by GPs/dieticians
composition varies
tolerance/compliance varies

Question 7

When to use a nasogastric feed?

Answer 7

inpatients with poor appetite and not meeting nutritional requirements

poor appetite/wound healing

stroke patients with dysphagia

after surgery

intensive care patients sedated and on ventilator

Question 8

What is nasogastric feed?

Answer 8

temporarily unable to meet nutritional requirements

usually under 1 month

Question 9

What is purpose of gastrostomy?

Answer 9

neurological swallowing problems, cognitive impairment, mechanical obstruction

long term >1 month

high post insertion mortality if places inappropriately

Question 10

What is a jejunostomy?

Answer 10

upper GI obstruction, fistula (neoplastic disease of stomach/duodenum)

Question 11

How to determine how much to feed?

Answer 11

indirect calorimetry

weight based equation/predictive equations (25030kcal/kg)

Question 12

Enteral feeding complications?

Answer 12

nausea/vomiting

• medication
• high feed volume
• delayed gastric emptying

tube issues

• pain, laryngeal ulcers
• tube blockage
• misplaced into lungs

diarrhoea

• intestinal infection
• medication
• malabsoprtion
• constipation

metabolic

• over/under feeding
• refeeding syndrome

Question 13

Long term complications of parenteral nutrition?

Answer 13

high risk of infection and sepsis
pneumothorax
line sepsis
bleeding 
misplacement/break/leak
REFEEDING SYNDROME

Question 14

Enteral feeding complications?

Answer 14

nausea/vomiting

• medication
• high feed volume
• delayed gastric emptying

tube issues

• pain, laryngeal ulcers
• tube blockage
• misplaced into lungs

diarrhoea

• intestinal infection
• medication
• malabsorption
• constipation

metabolic

• over/under feeding
• refeeding syndrome

Question 15

Long term complications of parenteral nutrition?

Answer 15

high risk of infection and sepsis
pneumothorax
line sepsis
bleeding 
misplacement/break/leak
REFEEDING SYNDROME

Question 16

Main advantages/dis of enteral feeding?

Answer 16

ADV
fewer risk of side effects
less invasive (nasogastric) vas parenteral
uses gut
at bedside
cheap
at bedside
low level monitoring
use long term (PEG - gastrostomy tube)

DISADV
metabolic problems 
nausea/vomiting
tube misplace/blockage/aspiration into lungs
hypo/hyperglycaemia

Question 17

Main advatnages/dis of parenteral feeding?

Answer 17

ADV
can meet nutritional needs when GI tracts inaccessible

DISADV
expensive
line places in radiology
aseptic conditions
complications (pneumothorax)
metabolic/electrolyte complications
close monitoring

Question 18

What is refeeding syndrome?

Answer 18

syndrome with metabolic disturbances after re-instituting nutrition to patients who are starved or severely malnourished
usually if starved from >5 days

1. chronic malnutrition, prolonged fast
2. metabolic effects of starvation (glycogenolysis, gluconeogenesis)
3. feed patient (increase uptake of glucose/phosphorus/Mag/K)
4. need to supplement if levels too low

low K, Mg and phosphate consequences: MI, arrhythmia, ventilatory fail, paralysis, weakness

Question 19

How to monitor and treat refeeding syndrome?

Answer 19

Daily biochemistry
vitamin supplementation
nutrition support at 10kcal/kg/day