Nutrition Flashcards
Screening tool for malnutrition
Malnutrition Universal Screening Tool(MUST)
Feeding preference if unable to eat sufficient calories
Oral nutritional supplements(ONS)
Feeding preference if unable to take sufficient calories orally or dysfunctional swallow
Nasogastric tube feeding tube(NGT)
Feeding preference if oesophagus blocked/dysfunctional
Gastrostomy feeding(PEG/RIG)
Feeding preference if stomach inaccessible or outflow obstruction
Jejunal feeding(jejunostomy)
Feeding preference if jejunum inaccessible or intestinal failure(IF)
Parenteral nutrition
SNAP mnemonic for any patients with intestinal failure
Sepsis - Infection present must be corrected, otherwise feeding will be largely useless
Nutrition - Once infection is corrected, suitable nutrition should be provided
Anatomy - Define anatomy of GI tract so that surgery can be planned
Procedure - Definitive surgery once any infection eradicated, the patient nourished, and the anatomy defined
What is ERAS
Enhanced recovery after surgery:
Reduction in ‘Nil by Mouth’ times
Pre-op carbohydrate loading
Minimally invasive surgery
Minimising the use of drains and nasogastric tubes
Rapid reintroduction of feeding post-operatively
Early mobilisation
Medical management of high output stoma
Reduction in hypotonic fluids
Reduction in gut motility with high dose loperamide and codeine
Reduction in secretions with PPIs
Use of WHO solution to reduce sodium losses
Low fibre diet to reduce intraluminal retention of water
What is parenteral feeding
IV administration of nutrients
May be supplemental to oral or tube feeding, or it may provide only source of nutrition as total parenteral nutrition(TPN)
Peripheral lines vs central access for parenteral feeding
Peripheral lines may be used to deliver short-term nutritional support, but central access is necessary for feeding of more than two weeks’ duration
Optimal method of access for central catheters
Ideally tunnelled subclavian vein central lines, inserted using the full aseptic technique
Parenteral nutrition solution is thrombogenic and an irritant to veins
Method of peripheral administration in parenteral nutrition
Achieved through peripherally inserted central catheters(PICCs) or standard cannulae, inserted with an aseptic technique
Tolerance to peripheral lines is increased with feeds of low osmolality and neutral pH and the use of soft paediatric cannulae
Which form of imaging can aid in getting access to central veins
Ultrasounded-guided venepuncture
Feed preparations for TPN solutions
Iso-osmotic lipid emulsions are used to provide an energy-rich solution and reduce irritation of veins
How should parenteral nutrition be introduced
Introduced at a low rate and gradually increased
TPN is usually delivered at a continuous flow rate but cyclical regimens may suit longer use
Complications of parenteral feeding
Re-feeding syndrome Cath related complications Infection Liver and gallbladder dysfunction Hyperglycaemia
What is re-feeding syndrome
Intracellular electrolyte stores, particularly phosphate, are depleted during starvation despite normal serum conc
Feeding stimulates cellular uptake of electrolytes and can lead to electrolyte disturbances with profound hypophosphataemia
Clinical features of re-feeding syndrome
Usually develop within 4 days of re-feeding, but are often nonspecific
Later manifestations include rhabdomyolysis, cardiac failure, hypotension, arrhythmias, resp failure, seizures and coma
Catheter-related complications of parenteral feeding
Immediate complications include haemorrhage, pneumothorax or haemothorax, arrhythmias or cardiac tamponade.
Long-term complications include thrombosis and pulmonary embolism, pleural or pericardial effusion, subacute bacterial endocarditis, chylothorax and venopulmonary fistula.
Features of liver and gallbladder dysfunction in parenteral feeding
Majority develop mild cholestasis with elevation of transaminases and alkaline phosphatase
Gallstones and gallbladder sludging may also occur
NICE advice regarding use of enteral feeding for post-op patients
Persons having surgery should not have enteral feeding within 48 hrs after surgery unless they have:
Inadequate or unsafe oral intake; and
a functional, accessible GI tract
Features of NG tubes
Depend on adequate gastric emptying
Allow use of hypertonic feeds, high feeding rates and bolus feeding into the stomach reservoir
Tubes are simple to insert but are easily displaced
Features of NJ tubes
Reduce incidence of GORD and are useful in delayed gastric emptying
Post-pyloric placement can be difficult but may be aided by IV prokinetics
Indications for PEG tubes
Stroke
Motor neurone disease
Parkinson’s disease
Oesophageal cancer
Relative contra-indications to PEG tubes
Reflux Previous gastric surgery Gastric ulceration Malignancy Gastric outlet obstruction
How are PEG tubes inserted
Inserted directly through the stomach wall endoscopically or surgically under antibiotic cover
Features of pre-digested feeds
Contain nitrogen as short peptides or free amino acids and aim to improve nutrient absorption in the presence of pancreatic insufficiency or inflammatory bowel disease
Fibre content of feeds is variable and some are supplemented with vitamin K, which may interact with other meds
Complications of NG tube
Nasopharyngeal discomfort and later nasal erosions, abscesses and sinusitis
Acute complications such as pharyngeal or oesophageal perforation
Complications of PEG or jejunostomy tubes
Can lead to complications related to endoscopy plus bowel perforation and abdominal wall or intraperitoneal bleeding
Post-insertion complications include stoma site infections, peritonitis, septicaemia, peristomal leaks, dislodgement and gastrocolic fistula formation
Purpose of propping patients up by at least 30 degrees whilst feeding and 30 mins after
To minimise the risk of aspiration
Reflux occurs frequently(esp in patients with impaired consciousness, poor gag reflex and when fed in the supine position)
GI symptoms of enteral feeding
Abdominal bloating Cramps Nausea Diarrhoea Constipation
Monitoring for enteral feeding
Position of nasally inserted tubes, which should be checked before each feed by obtaining tube aspirate of pH < 5.5 on pH paper
Development of erosions
Gastrostomy and jejunostomy stoma sites should be checked for infection
