Managing EN Complications Flashcards
1
Q
How to manage GRVs?
A
- Start prokinetic as 1st line therapy (Metoclopramide, erythromycin)
- Change En regimen to a higher density formula
- Switch En administration from gastric to post-pyloric
- Elevate HOB to at least 30-45 degrees
2
Q
According to the MUHC algorithm, all _____ patients should be evaluated for ______ in Step 1.
A
- Gastric fed patients
- Aspiration
3
Q
The MUHC algorithm requires to confirm ______ before initiating ___ in Step 2
A
- Feeding tube in place
- Feeds
4
Q
The MUHC algorithm indicates that an elevated HOB of ______ during feeding unless _____ in Step 3.
A
- 30-45 degrees at all times
- Contraindicated
5
Q
The MUHC algorithm indicates that measuring GRVS ____ for the first 48 hours as Step 4.
A
q4h
6
Q
After Step 4, what does the MUHC algorithm recommend if GV <250 ml? In non-critically ill? Critically ill?
A
- Re-instill gastric contents and progress feeds per protocol until EN goal rate achieved
- In non-critically ill, continue to monitor GRVs q8h and discontinue after 48h if no sign of intolerance
- In critically-ill, continue to monitor GRVs q4h
7
Q
After Step 4, What does the MUHC algorithm recommend if GRVs between 250-500 mls and there is no signs of intolerance?
A
- Re-instill 250 ml gastric contents
- Resume feeds are currently tolerated rate
8
Q
After Step 4, What does the MUHC algorithm recommend if GRVs between 250-500 mls and signs of intolerance?
A
- Re-instill 250 ml of gastric contents
- Inform MD and Clinical Dietitian
- Consider replacing with small bowel feed or initiate pro-kinetic
9
Q
After Step 4, What does the MUHC algorithm recommend if GRVs >500 ml ?
A
- Discard aspirate
- Inform MD and Clinical Dietitian
- Proceed as per MD assessment
10
Q
What is aspiration?
A
The inhalation fo material into the area, which often included gastric contents or tube feeding formula
11
Q
What is a complication of aspiration?
A
Aspiration pneumonia
12
Q
List the common complications of EN?
A
- Refeeding syndrome
- GI complications
- Aspiration
- Metabolic alterations
- Dehydration
- Tube related complications
13
Q
Discuss re-feeding syndrome
A
-The intracellular shift of fluids, electrolytes and minerals that occur during the repletion of a severely malnourished or starved patient –> Shift from fat to CHO utilization
14
Q
Hallmark sign of re-feeding?
A
Hypophosphatemia, hypomagnesia and hypokalemia
15
Q
(T/F) Re-feeding may be caused by D5W
A
True, as the dextrose may be enough to elicit the insulingenic response
16
Q
Energy and dextrose protocol to prevent refeeding?
A
- <25% of goal energy on day 1, an work towards goal in 2-5 days
- = 1.5 g/kg/day of dextrose
- Increase rates as tolerated, and monitor intake, output and patient weight
17
Q
What should dextrose not exceed on day 1? What if at high risk of RF?
A
- 200 g/day
- 100 g/day
18
Q
Who is at risk of refeeding?
A
1) When patient has one or more of the following
- BMI <16 kg/m^2
-Unintentional weight-loss greater than 15% in 3-6 mo
-Poor or no intake for >10 days
-Low K, P or Mg prior to feeding
OR
2) Alternate criteria
19
Q
What is the alternate criteria which may indicate a patient at risk for refeeding?
A
2) Patient has two or more of the following:
- BMI <18.5
- Unintentional weight loss >10% within 3-6 mo
- Poor or no intake for >5 days
20
Q
What are other risk factors for re-feeding?
A
- Malnutrition
- Poorly controlled diabetes
- Cancer
- AN
- Short bowel syndrome, IBD
- Elderly
- Low birth weight
- Chronic infections
21
Q
What can RF lead to?
A
- Arrhythmia’s
- Respiratory and cardiac failure
- Aspiration
- Death
22
Q
(T/F) Electrolyte deficiencies can occur in the presence of normal serum levels
A
T
23
Q
What should be administered to prevent and treat RF?
A
- Thiamine
- Phosphate
- Potassium
- Magnesium
24
Q
Thiamine in RF?
A
5-10 mg/day of thiamine through IV
-may be higher, 50-300 mg or 100 mg for 5 days depending on severity
25
When may aggressive thiamine repletions of 100mg x 5days be warranted?
-Vomiting
-Gastric Sx
-Alcoholism
-
26
What kind of phosphate supplement is typically used?
- Potassium phosphate, unless potassium is > 4 mmol/l
| - We can treat electrolyte deficiencies together
27
Normal serum phosphate?
3.-4.5 mg/dl
28
Mild serum phosphate and corrective IV phosphorus dose?
- 2.3-2.7
| - 0.08-0.16
29
Moderate serum phosphate and corrective IV phosphorous dose?
- 1.5-2.2
| - 0.16-0.32
30
Severe serum phosphate and corrective IV phosphorus dose?
- <1.5
| - 0.32-1
31
Why is magnesium difficult to dose and treat?
-We don't have a reliable sense or maker of body magnesium, or the amount fo magnesium truly in foods
32
What is the maximum infusion rate of mg in asymptomatic ?
-8 mEq/h and up to 96 mEq over 12 hours
33
What is the maximum infusion rate of mg in severe, symptomatic hypomagensemia?
-Up to 32 mEq over 4-5 mins
34
A total body deficit of ____ of K is required before serum values drop below normal
80 mEq
35
Why do serum levels of magnesium not necessarily correlate with intracellular concentrations or total body magnesium levels?
-Because only 1-2% of mg is located in the ECF
36
Incidence of N/V with EN?
7-26% of patients
37
Risks associated with N/V?
-Aspiration, pneumonia and sepsis
38
Etiologies of N/V? Are they often associated with EN?
- -> Not most linked to EN, however some that may be attributed to EN include:
- Rapid infusion
- Delayed emptying
- Cold EN solutions
39
Management of N/V is EN patients?
- Discuss alternative meds, such as narcotics (to slow down GI motility)
- Lower fat EN, room temp and isotonic
- Create osmolality closer to blood
- Rule out C.Diff
40
Feeding rate and deliver modifications in N/V?
- Consider switching from bolus to continuous
- If continuous, reduce rate by 20-25 ml/hour
- Monitor GRV q4h or before bolus
41
Discuss non EN causes of N/V?
- Hypotension
- Sepsis
- Stress
- Anesthesia and Sx --> *almost in all patients*
- Whipples
- Opiate meds, anticholinergics --> sorbitol containing
42
You are at the MUHC and have been asked to review the chart for a patient with abdominal distention and vomiting, you review the chart and learn the following:
o Mx: MVA (motor-vehicle accident), NS (normal saline) in view of head trauma, tube access available
o EN was continuous feed using NG and well tolerated, recently switched to bolus feeds with same formula; osmolyte 1kcal/ml
```
Which of the following strategies would NOT be a likely approach to manage this case?
A) Check GRV before next bolus
B) Revert back to continuous feeds
C) Add a prokinetic agent
D) Request stool cultures
```
D)
43
If the GRV is 300 ml, what would the nurse do?
-Return the GRC and administer pro-kinetic agent
44
If the GRV is 500 ml, what would the nurse do?
Revert to continuous feeds
45
What is the objective assessment for abdominal distension?
8-10 cm increase of abdominal girth
46
Common causes of abdominal distension?
-Ileus, obstruction, obstipation, ascites, diarrheal illness
47
When may distension be related to EN?
- Rapid administration
- Cold EN
- Fibre containing EN
48
Management of distention?
- Visual inspection and palpitation
| - X-ray/contrast studies
49
In the context of distention, when may we continue EN? Discontinue?
- Continue if intestinal appearance and function appears normal
- Discontinue if motility os poor or there is marked distention
50
What may be done if EN cannot be continued to to distention?
- Initiation of PPN or CPN
| - Or, stop EN, then continue with EN feeds
51
What should be done if we suspect EN is causing distension?
Look up the product formulary
| -Consider switching if osmolality, fat and fibre is notably high
52
What is maldigestion and malabsorption associated with?
-Bloating, distention, diarrhea, unexplained weight loss, steatorrhea, diarrhea, tetany, bone pain
53
How do we diagnose maldigestion and malabsorption?
- Stool sample (i.e fecal fat in steatorrhea)
- Absorption tests (Shillings, d--xylose, however may aggravate cramping/diarrhea)
- Small bowel biposy
54
(T/F) Most causes of maldigestion and malabsorption are not due to nutritional causes
T
55
What are some common GI causes of maldigestion and malabsorption?
-Gluten-sensitive enteropathy, Crohns disease, fistulas, short-gut syndrome, diverticular disease
56
What are some other causes of maldigestion and malabsorption?
- Radiation enteritis
| - HIV, pancreatic insufficiency
57
What could we do when we have a patient who is a good candidate for EN, put posses maldigestion or malabsorption issues?
- Consider disease-modulated formula's (Hydrolyzed proteins, MCT oils) before PN
- Start low and slow and increase as tolerated
58
Why is MCT oil preferable when there is lower GI absorption issues?
-MCT is absorbed higher up in the duodenum and jejunum
59
What is defined as diarrhea?
>750 ml/day or >3 stools/day for 2 days
60
What are causes of diarrhea?
- Medications
- Infections (C. Diff)
- En formulation
61
Medications and diarrhea?
Sorbitol based, hypertonic, anti-biotics
62
En formulations and diarrhea?
- High osmolality, high fat, high fibre
| - Note that underfeeding could also cause malabsorption and diarrhea
63
Notable sorbitol-containing medications? (FANHL-MADIC )
- Furosemide
- Acetaminophen
- Notriptyline
- Hydroxyzine
- Lactulose
- Amantadine
- Doxycycline
- Isoniazid
- Metoclopramide
- Cimetidine
64
Management of diarrhea?
- MD to R/O infections, inflamamtion, fecal impaction and medications
- Suggest switching medications
- Add anti-diarrheal agent if not bacterial
65
How may medications be altered to manage diarrhea?
- Switch medication if hypertonic or dilute in sterile water
| - Use medications with non-sorbitol fillers
66
EN management of diarrhea?
- Choose EN to lower osmolality and lower fat, try MCT
- Choose En with soluble fibre
- Use PN if prolonged malabsorption
67
Diarrhea is indicated and there is a distended, tympanic or painful abdomen, how should we progress?
-D/C EN, and MD to review patient and consider TPN
68
Diarrhea is indicated and there is NO distended, tympanic or painful abdomen, how should we progress?
- R/O medical or Sx treatments which may be causing the complication
- IBD, terminal ileys, chemo, SBS, pancreaic insufficiency
- Intervene as needed
69
We R/O medical or Sx trt as causing the diarrhea, how to we progress?
- R/O Risk of stool impaction
| - Intervene with rectal exam, disimpactions, x-ray to r/o proximal impaction
70
When is stool impaction indicated?
- Chronic constipation w/ absent BM x 5 days
- Regular narcotic use
- Limited fluid intakes
71
We R/O risk of stool impaction, how do we progress?
- R/O cause from cathartic agents (citromag, docusate, milk of magnesia)
- Intervene with changing med to IV, administer oral electrolytes via PN routs, and consult pharm
72
We R/O cathartic agents, how do we progress?
- R/O C.Diff, ischemia
| - If still not indicated, consider EN with fibre
73
Diarrhea remains unresolved after R/O C.Diff, ischemia and providing EN with fibre, how do we progress?
-Initiate anti-diarrheal agent, and reassess need/dosage daily
74
A surgical patient receiving EN previously as continuous feed 16 h/d, (isosourceHN) was medically managed for nausea and GRV > 250 ml develops diarrhea. The following medications are delivered through the feeding tube: metoclopramide and cimetidine.
- Metoclopramide and Cimetidine are known for their high sorbitol content, which may be causing diarrhea
- Consider switching meds or deliver one through IV
75
Which conditions are associated with secretory diarrhea? (A-3I-3C-BF-SMZV)
- Abuse of laxatives
- Infection, Intestinal resections, IBD
- Celiac sprue, collagen vascular disease, congenital defects
- Bile acid malabsorption, Fatty acid malabsorption
- SI lymphoma, Malignant carcinoid syndrome, Zollinger-Ellison syndrome, Villius adenoma of rectum
76
How can we manage secretory diarrhea?
-Specialized formula or PN
77
Constipation stool patterns?
BM once every 4-5 days, evidence of fecal waste in the transverse colon and can be up to the cecum
78
Management of constipation by RD?
- Adequate hydration of 1ml/kcal, check flush volumes
- Consider soluble fibre formulation, avoid modulars to prevent clogging tubes
- Reassess with new medications (softeners, laxatives, enemas)
79
What are less common complications of EN?
- Bacterial Overgrowth
| - Contamination of EN
80
When is bacterial overgrowth observed?
- Observed in surgical resections, especially the blind loops created in Roux-en-Y gastric by-pass Sx.
- Whipples procedure
81
What is blind-loop syndrome?
The presence of this "blind loop" means food may not move normally through the digestive tract.
Slowly moving food and waste products become a breeding ground for bacteria. The result — bacterial overgrowth — often causes diarrhea and may cause weight loss and malnutrition.
82
What can bacterial overgrowth cause?
- Enteritis
- Diarrhea
- Abdominal cramping
- Hypoalbuminemia
- Catabolism and cachexia
- Fever, sepsis
83
How can we Dx bacterial overgrowth? Tx?
- H2 breath test and consider anatomy
| - Treat with antibiotics
84
When are hang-times of formulary indicated?-
- LTC
| - At home
85
When should open systems be cleaned to avoid contamination?
Every 24 hours
86
Hang-time for blended EN? (open)
4-hour max
87
Hang-time for sterile package EN? (open)
4-12 hour
88
When may closed systems be contaminated?
- Spike contamination or EN times too longs
| - Ensure proper flushing of meds (in both open and closed systems)
89
You have patient receiving EN support. The total volume is 2000 ml/day continuous over 16 h, and you are using modular feeds mixed and delivered in an open system
What can you do to minimize contamination of the EN and signs of intolerance?
- Ensure hand washing
- Use sterilized blender
- Watch the temperature of the feed (make sure it is room temperature)
- Ensure OK hang time
- Suggest switching to closed system
- Ensure flushing if medications
90
What is necrotizing enterocolitis?
Bowel necrosis, a form of intestinal ischemia
91
How can we prevent and prevent necrotizing enterocolitis?
- Begin when hemodynamically stable and hydrated
| - Stat with isotonic feed (similar to blood, mother mil)and small amounts
92
What should we do if necrotizing is expected?
-D/C EN and MD to further evaluate GI and consider TPN
93
When should no fibre be indicated in EN?
- If risk of intestinal ischemia is present
| - All age groups
94
What are symptoms of aspiration?
- Respiratory symptoms
- Agitation
- Infections (Pneumonia, with a higher risk in older age)
95
Who is at greater risk of aspriation?
- GERD
- Gastric feeds
- HOB not elevated sufficiently
- Coma
96
How can we prevent aspiration?
- GRVs every four hours
| - HOB 30-45
97
When are GRV's harder to evaluate?
- G-tube/PEG
- But, lower risk of aspirations
- Guidelines not 100% clear
98
Your long-term patient has developed pneumonia, they are on EN and have tolerated it for a long time. How can you rule out aspiration of EN as a cause?
- If long-term, it is likely not the tube feeding
- Check the placement of the feed
- R/O other sources of pneumonia besides aspiration
99
You have another patient on NG feeds with GRV of 200 ml q4h, what can you do to minimize risk of aspiration?
- Elevate the HOB
- Continue with GV q4h
- Add a pro-kinetic agent
100
List metabolic alterations that are related to EN (But more common with PN)
- Hypertonic dehydration
- Over-hydration
- Hypokalemia
- Hypophosphatemia
- Hypercapnia
- Vitamin K deficiency
- EFAD
- HyperG
101
Hypertonic dehydration?
- May occur with concentrated EN
- Go for more fluids
- Monitor serum electrolytes and specific gravity
102
Over hydration?
- May occur in rapid refeeding, refeeding syndrome
- Go for less fluids, try concentrated EN
- Check aldosterone levels, which may be elevated in sodium retention
- Adjust water flushes
103
Hypercapnia?
- High blood Co2
- May occur in overfeeding and excess CHO in states of respiratory dysfunction
- Consider low phosphate formula, ensure proper energy (IC)
- Consider providing 30-50% of E as fat
104
Vitamin K deficiency?
- Prolonged EN with low fat or low vit K
- Supplement vit K and consider probiotic agents
- Also depends on function of colon which synthesizes vitamin K
105
Hyperglycemia?
- Try using SS insulin, long-acting insulin
- Try continuous feeds vs. bolus feeds
- Try more fibre to delay gastric emptying
106
When may hyperG be unavailable?
During the catabolic response to stress or surgery
| -Patients cannot properly clear blood glucose
107
Is fibre warranted for an ICU patient with hyperglycemia?
No
108
When should blood glucose levels be corrected?
Preferable before initiating TF , then monitor serum glucose levels every 6 hours
109
What may be considered to stabilize blood sugars?
- Provide OHA or insulin therapy
- Consider providing 30-50% energy as fat
- Consider using a product with fibre
110
Would fiber be appropriate for a patient with gastroparesis ?
-Not usually, as we do not want to further compromise a decreased ability in gastric emptying
111
When may dehydration occur?
-Increased fluid needs compared to intake, increased losses, missed feeds
112
What may aggravate, or cause dehydration
- Insufficient water intake
- Fever, diarrhea, N/V
- Blood loss
- Diabetes, kidney disease
- Diuretics, drainage tubes, fistula, ostomy
113
Vulnerable groups for dehydration?
- Aging (less lean mass)
| - Young children
114
What does dehydration do?
Causes a higher morbidity and mortality rate
115
Increased short-term morbidities associated with dehydration?
-Higher risk falls, pressure ulcers, constipation, UTI, respiratory infections, medication toxicity
116
Increased long-term morbidities associated with dehydration?
- Delirium
- Renal failure
- Coma and death
117
How can we dx dehydration?
- No clear approach
| - Collaborate with teams to assess tongue, sunken eyes, vision, muscle ramps, delirium, skin turgor, BP, biochemistry
118
Management of dehydration?
- Ensure flush volumes, missed feeds replaced
- Increase fluid 12% per degree >37.8
- IV fluid support may be needed
119
How should we monitor patients with dehydration?
- Urine output (30 ml/h or 700 ml/day)
- Plasma osmolality
- HCT
- BUN:C ration >20:1
120
What should be considered in preventing EN complication?
- Ensure proper hygiene of skin and catheter care
| - Consider nasal, oral and stoma care
121
When may clogging occur?
- Improper flushing before and after medications
- High protein/energy/fibre EN
- Medication crushed into tube, compared to fluid/IV
122
How can we progress clogging?
Try use of pancreatic enzymes
123
Which tubes have additional concerns about placement?
-NG and NJ tubes
124
Risks of misplacement of NG and NJ tubes?
- Bronchopulmonary tree
- Dislodgement of the nasal bridle
- Malfunction, cracking of tubes
- Aspiration, sinusitis
- Intestinal ischemia
125
What is a nasal bridle?
Re-inforce the tube to make sure it cannot be pulled, and will stay in place.
-Usually in younger patients, dementia and alzhiemers
126
Risks after placement of enterostomy and G/J tubes?
- Peristomal infection
- Necrotizing facitits
- Leakage
- Buried bumper
- Pulling tubes
- J-tube: Occlusion, volvulus, perforations
127
When should we wait to exchange/remove an enterostomy or G/J tubes?
- More than 2 weeks after placement to ensure that the stoma heals
- Consider 4-6 weeks in immunosuppressed, obese, or those with delayed healing
128
What is a volvulus ?
A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction.
