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GI > Module 5: Nutrition Dr. Covert > Flashcards

Module 5: Nutrition Dr. Covert Flashcards

EXAM VI

1
Q

What are the different routes of enteral nutrition?

A

-uses GI tract
-PO
-per feeding tube (still enters the GI)

if the GI tract has not been used after a period of time, the peristalsis is less active

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2
Q

What are the different routes of parenteral nutrition?

A

-IV
-does NOT use GI

-parietal cells not active, no peristalsis, pancreas will not secret enzymes, no gut stimulation

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3
Q

Pros of Enteral Nutrition

A

-stimulation of the gut (keep GI functioning, peristalsis)
-lower risk of infection
-less hepatic/biliary complication (bc still used and stimulated)
-decrease in hyperglycemia (fewer glycemic swings when eating carb-rich food)

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4
Q

Cons of Enteral Nutrition

A

-Aspiration (pneumonia)
-may induce diarrhea (high osmotic load in the formula)
-malabsorption (bc it moves so quickly through the body)
-hyperglycemia
-tube irritation (uncomfortable)
-tube occlusion

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5
Q

Which patient population is eligible for enteral nutrition?

A

-functional GI tract!
-unable to take PO
-safe enteral access possible (patients ripping their tubes off)
-critical ill patients

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6
Q

Patients excluded from enteral nutrition

A

-intestinal obstruction (eg esophageal cancer)
-bowel ischemia, Crohn’s disease
-active peritonitis
-severe pancreatitis
-severe hemodynamic instability (less perfusion to the gut due to low BP)

-toxic megacolon in C. diff (removing a big part of the colon - can’t absorb food or meds)

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7
Q

What are the surgically placed tube insertions?

A

-PEG (short-term)
-PEJ (short-term)
-J-tube (long-term)

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8
Q

Which tubes may be used if a patient is unconscious and needs quick access?

A

NG tube
NJ tube
ND tube
Orogasstric (OG)

via stomach = short and long-term

-works quickly, short-term
-can give food and crushed meds

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9
Q

What are the Formulations for food delivery?

A

-Continuous: 16-24h/day -> small volume over time, les N/V, but it is not physiologic to continuously be fed

-Cyclic (larger volume over a shorter period of time)

-Intermittent (large volume at once, often outpatient)
-Bolus (large volume at once, often outpatient)
+ sorter duration for being on the feeding tube

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10
Q

What are the physiological disadvantages of continuous administered nutrition?

A

-it is not physiologic
-blood sugar dysregulation
-constant pancreatic secretion of enzymes and insulin

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11
Q

ADR of enteral nutrition

A

-GI intolerance
-tube occlusion
-aspiration
-fluid/electrolyte changes
-hyperglycemia
-dehydration (need free water)

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12
Q

Monitoring - Enteral nutrition

A

-weight
-BMP (K, glucose)
-Mg/Ph
-volume status (TNP with high calories in low volume, may need supplemental free water, in ESRD of HF patient is may be fine bc they won’t tolerate fluids anyway)

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13
Q

Medication Considerations - Site of action
EXAM

A

Drug use with tubes
-site of action: J-tube works in the jejunum, parietal cells are only present in the stomach -> so take off PPIs; enteric-coated drugs meant to bypass the stomach -> when used in NJ tube they would be released further down the stomach
-take off carafate it works in the stomach

-site of absorption: often rely on an acidic environment, which is bypassed with J-tubes and NEJ tubes

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14
Q

Medication Considerations - Liquid formulas
EXAM

A

-liquid meds with high osmotic load, fe Augmentin has a lot of sugar
-irritating to the gut -> diarrhea
-stomach upset

when switching from PO to liquid the volume might be so high that is not tolerable for the patient

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15
Q

Why should meds never be mixed with enteral formula?

Medication Considerations
EXAM

A

-meds will bind, and interact with the food, and may deactivate

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16
Q

Why must the tube be flushed after giving meds?

A

-long tube -> long way to travel
-flush after giving the meds to make sure everything goes through

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17
Q

Can drugs be crushed?

A

-for most immediate-release meds it is fine
-not for extended-release meds -> it may release the entire dose at once - overdose
-fe MS Contin, 5-ASA (enteric-coated)

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18
Q

What needs to be considered when giving Phenytoin to patients on enteral nutrition?

A

-Hold feeds 1-2h before and after giving Phenytoin to prevent decreased absorption (given TID - not easy to manage)
-low absorption when given with enteral nutrition -> may not be able to prevent the seizure

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19
Q

What needs to be considered when giving Warfarin and FQ to patients on enteral nutrition?

A

Warfarin:
-adjust Warfarin to INR
-some EN formulas have more or less Vitamin K content

FQ:
-hold feeds 1-2h before and after giving FQ
-lower bioavailability due to chelation with cations in the EN formula

20
Q

What are the Macronutrients in Parental Nutrition?

EXAM

A

-Protein: 4 kcal/g

-Fat: 9 kcal/g

-Carbohydrates: 3.4 kcal/g

21
Q

Pros of Parental Nutrition

A

-don’t rely on the GI function

22
Q

Cons of Parental Nutrition

A

-infection
-hepatic or biliary complications -> constantly stimulating bile acid secretion to breakdown fats in the formula -> gallstones, gallbladder slugging

-catheter thrombosis
-hyperglycemia
-electrolyte abnormalities
-osteoporosis (long-term) bc less Vitamin K absorption

23
Q

Who is eligible for Parenteral Nutrition?

A

.-patients with Malabsorption who can’t be fed by enteral nutrition for 7-10 days

-Bowel resection
-Bowel obstruction
-GI fistula
-severe cancer in the gut

-patients with functional GI should get enteral nutrition!

24
Q

Partial Parental Nutrition (PPN)

A

-via small vein (due to osmolality)
-temporary
-does not provide full nutrition

-PPN not often used anymore

25
Q

Total Parental Nutrition (TPN)

A

-via large vein, a large vein is needed bc of the high osmotic load
-may be used long-term
-can provide full nutrition

26
Q

Which factors are used to assess a patient’s eligibility for TPN?

A

-Body weight
-BMI
-Nutrition history (how long have they been NPO, nothing by mouth)
-physical exam

27
Q

What is refeeding syndrome

A

-feeding patients too quickly after malnutrition for a long period of time

-the body’s metabolism has shifted to breakdown as an energy source -> when refeeding to quickly it shifts back to carb metabolism to use carbs as an energy source

-it causes a spike in insulin -> reduces blood sugar -> hypoglycemia

-for the body to use the energy from the carbs -> the body needs phosphorus to generate ATP -> high demand and depletion of phosphorus (lower than 1) -> leads to cardiac arrhythmia -> may cause death

28
Q

How to manage refeeding syndrome

A

Monitor: electrolytes, glucose, feed slowly
-give 50% of daily intake

29
Q

Risk factor of Refeeding Syndrome

A

+1
-BMI < 16
-unintentional weight loss by 15% in the last 3-6 months
-little or no nutrition for 10 days
-Low K, Phos, Mag before feeding

+2
-BMI < 18.5
-unintentional weight loss by 10% in the last 3-6 months
-little or no nutrition for 5 days
-H/ EtOH/ drug use

30
Q

When to use actual BW vs IBW

A

-BMI <30: actual BW
-BMI >30: IBW

31
Q

When is a total caloric intake of 25-30 kcal/kg/day recommended?

STEP 1 Calories

A

-most patients
-maintenance
-elective surgery
-medical ICU
-minor infection
-minor surgery

the weight (TBW vs IBW) that is used depends on the BMI

32
Q

When is a total caloric intake of 30-35 kcal/kg/day recommended?

STEP 1 Calories

A

-major trauma
-major surgery
-major stress

33
Q

What does the number of calories tell me?

A

-total number of calories per day
-so protein, fats, and carbs together has to equal the number of calories

34
Q

What are the Protein needs for different patient populations?

STEP 2 Protein

A

-Maintenance (home TPN): 1g /kg/day

-moderate stress: 1.5 - 2g /kg/day
-severe stress: 2 - 2.5g /kg/day

-renal impairment:
Non-HD: 1.2g /kg/day
HD: 1.2 - 1.5g /kg/day
CVVHD: 2 - 2.5g /kg/day

35
Q

How would the daily protein needs be adjusted in patients with renal impairment?

A

-reduced protein needs bc the kidneys are responsible for processing proteins

36
Q

How many calories are in 110g of Protein?

A

4 kcal/g
110 g x 4 kcal = 440 kcal

1800 total kcal -> so 1360 kcal left (non-protein calories)

37
Q

Fat/Lipids

Step 3

A

-20-30% of the non-protein calories should come from fat (fat should not exceed 60% of non-protein calories -> hypertriglyceridemia)

OR

0.5 - 1g/kg/day

consider drugs with large fat content

38
Q

Which medications are known to have a high-fat content?

A

-Propofol: 1.1 kcal/ml

-Clevidipine: 2 kcal/ml

39
Q

What are the prepared fat products?

A

-SMOFlipid (preferred, less inflammatory)
-Intralipid
-comes in 10% or 20%

40
Q

Calculation fat

A

1360 kcal left (non-protein calories)
-fat should be 20-30% of non-protein-calories
OR 0.5-1g/kcal/day -> fat = 9kcal/g
calculate 0.5 -1g from act BW -> multiply with 9 kcal
292-585 kcal/day

= 272-408 kcal should come from fat

-subtract the fats that came from drugs to determine how much should come from foods

41
Q

How much kcal should come from dextrose/carbs?

Step 4: carbs

A

~15-20 kcal/kg/day

-should not exceed 25 kcal/kg/day -> cholestasis (liver disease), difficulty weaning from the ventilator

-check what is left for carbs and divide by BW
-check if the result is in the range
-if too high increase fats or protein

42
Q

Step 5: Fluids

A

1st 10 kg: 100 ml/ kg = 100 * 10kg = 1000 ml
next 10 kg: 50 ml/kg = 50 * 10 kg = 500 ml
rest: 20 ml/k = 20 * (Wt - 20kg) (remaining of the BW)

-patients with HF might not get full amount of fluids bc it worsen their condition

43
Q

Step 6: Multivitamins and Trace elements

A

-multivitamins are usually already in the TPN

-Trace elements
MTE-5: Zinc, copper, chromium, manganese, selenium
MTE-4: no selenium (renal elimination so use for ESRD patients)

FYI:
-if renal disease: no selenium
-if liver disease: no manganese or copper
-high-output fistulas (>500ml/day): consider zinc supplements

44
Q

Step 7: Electrolytes

A

-trends of electrolytes can be managed via TPN
-> patient with HFrEF have chronically low K due to daily loop diuretic

-acute changes in electrolytes should be managed by boluses
-> fe hypokalemia secondary to fluid resuscitation due to septic shock

45
Q

How to replenish electrolytes

A

-replenish K: 10 meq = 0.1
PO is preferred bc IV irritation but he can’t get PO with Crohn’s disease
infusion rate:

-Mag controls K (replenish Mag first?)

-Phosphate:
NaPhos: 14-45 mmol
K Phos: 14-45 mmol -> can be given when the patient is low in K

-Ca2+: calcium gluconate (preferred IV): 2-3 g
(adjustment for albumin)

GI (19 decks)

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