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4152 CA2 > Nutrition > Flashcards

Nutrition Flashcards

1
Q

What are the two aspects of malnutrition?

A
  1. Decreased intake absorption
  2. Increased expenditure losses
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2
Q

Nutritional screening: ABCD

A

Anthropometric data (weight loss in past 6w, height)

Biochemical (electrolyte, albumin)

Clinical (disease state, medications, physical exam)

Diet (nutritional intake in past week)

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3
Q

What happens after screening?

A
  1. Nutritional screening
  2. Refer to nutritional specialist/dietitian
  3. Nutritional assessment (ONS / EN / PN / Palliative care)
  4. Formulation of nutritional regime
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4
Q

Calculation of Estimated Energy Requirements (EER)

A
  1. Indirect calorimetry
  2. Weight based: 25-35kcal/kg
  3. Predictive equations: estimates basal metabolic rate only, multiple by stress factor and physical activity
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5
Q

Calculation of Protein Requirements (EPR)

A

EPR = 0.8-1.5g/kg/day

In different disease states:

  • Healthy adult: 0.8
  • Trauma/burn/surgery: 1.5-2
  • Sepsis/critical illness: 1.5-2.5
  • CKD (ND): 0.6-0.8
  • CKD (HD/PD): 1.2
  • CKD (CRRT): 2
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6
Q

Based on guidelines, when to start EN for adult oncology patients?

A
  • Use EN in adult oncology patients who have solid tumors, are unable to receive oral intake, or >60-75% of goal nutrient intake, and who present with mod-severe malnutrition
  • Use EN in patients unable to tolerate >60% of energy and proteins by mouth despite oral supplementation for >7-14 days
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7
Q

Enteral access devices and their pros

A
  1. Pre-pyloric
  • More physiologic
  • Higher tolerance to bolus feeding
  • Higher tolerance to higher osmolarity
  • May be used for venting to minimize aspiration risk
  1. Post-pyloric
  • Less discomfort due to smaller bore
  • Lower aspiration risk
  • However, higher risk of tube clogging
  • However, lower tolerance to hyperosmolar feeds (isoosmolar ~300mOsmol/L)
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8
Q

Pros vs Cons of Bolus vs Continuous

A

Bolus

  • More convenient
  • More physiologic
  • However, higher risk of aspiration
  • However, less tolerated (bloatedness, abdominal discomfort)

Continuous

  • Lower risk of aspiration
  • Better tolerated
  • But less tolerated
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9
Q

Types of EN

A
  1. Modular
  2. Semi-Elemental / Elemental
  3. Polymeric
  4. Immune-modulating / Disease-specific
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10
Q

Drug-nutrient interaction with EN, how to mitigate/prevent

A

NIL for bolus/intermittent

Continuous
- precipitation
- crudling/clamping of protein (in acid environment)
- decrease drug activity due to destroyed release profile of drug (if drug cannot be crushed) - sustained release/enteric coated

Mitigate/prevent:

  • Stop feeding and flush feeding tube before and after drug administration
  • Use therapeutic alternatives - tablets that can be crushed / solutions
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11
Q

Common complications with EN

A
  • Occlusion of feeding tube (due to precipitation, adherence of highly concentrated feeds to inner walls, improper flushing technique)
  • Tube migration
  • Infections secondary to microbial contamination (do not add fluid into the feed, fluid should only be delivered through water flushes)
  • Aspiration
  • N&V
  • Diarrhea / Constipation
  • Refeeding
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12
Q

Monitoring parameters for pt on EN

A
  • Tolerability of bolus (abdominal pain and discomfort, bloating, N&V, aspiration)
  • Tolerance to EN (presence of undigested EN feeds in vomit/NG output/aspiration)
  • Tolerability of osmolarity of feed (diarrhea)
  • Refeeding (electrolytes)
  • Fluid overload - intake, output
  • Blood glucose levels
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13
Q

How to maximize tolerance to EN?

A
  • Bolus => Continuous
  • Pre-pyloric => post-pyloric
  • Isotonic formula
  • Prokinetic agent (Metoclopramide, Domperidone, IV Erythromycin) for N&V
  • Elemental feeds for those with malabsorptive issue
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14
Q

Parenteral access device

A
  1. Peripheral
  • Requires frequent resite every 72h
  • Limited by concentration and osmolarity (~900mOsmol/L)
  1. Central
  • Can accommodate large conc and osmolarity as quickly diluted by high blood flow
  • Types: non-tunneled central venous catheter, tunneled central venous catheter, peripherally inserted central catheter, port-a-cath

*Non-tunneled not used for >2w due to high risk of infection

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15
Q

Composition of PN

A

All in elemental form (as no digestion takes place)

Different compositions of Amino acids + Dextrose + Lipid emulsion + Electrolytes

TPN (no fats) VS TNA (3 in 1)

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16
Q

PN regimen:
Break down of EER = EPR + Dextrose + Lipids

A

EPR: 1g/kg/day (for unstressed patients)
Fats: 20-30% of EER or 1g/kg/day
Dextrose/Carbohydrates: 50-60% of EER or 4-5mg/kg/min

17
Q

Comment on stability and compatibility of PNs

A

Due to admixture of multiple elemental components,

  • Stability: lipid emulsion may be unstable
  • Compatibility: calcium and phosphates may precipitate, dextrose is acidic
18
Q

Drug-nutrient interaction of PN, how to prevent/mitigate

A
  • Not an issue if separate lumens
  • Need to check stability and compatibility for Admixture/Y-site

Administration of incompatible drugs may cause:

  • precipitation
  • decrease drug activity
  • phase separation of lipid emulsions
  • toxicity

PREVENTION/MITIGATION

  • Administer via separate cannula
  • Stop feeding, flush access tube before and after drug administration; *check blood glucose levels to prevent hypoglycemia
19
Q

Common complications of PN (device-related)

A
  • Occlusion (precipitation, thrombosis, lipid residues) *heparin lock, proper flushing technique, change administration set q24h
  • Catheter-related bloodstream infection *aseptic technique
  • Mal-positioning
20
Q

Common complications of PN (metabolic-related)

A
  • Refeeding syndrome
  • Hyper/hypoglycemia
  • Fluid overload
  • Metabolic bone disease
  • IFALD (Intestinal-failure-associated liver disease) - cholestasis, fatty liver, inflammation due to LCT component
21
Q

Refeeding syndrome management strategies

A
  1. Identify high-risk patients
  • BMI <16, unintentional weight loss >15% in past 3-6m, little or no nutritional intake >10d, low levels of electrolytes
  • BMI <18.5, unintentional weight loss >10% in past 3-6m, little or no nutritional intake >5d, hx of alcohol misuse, insulin, chemotherapy, antacids, diuretics
  1. Check baseline serum electrolytes
  2. Correct electrolyte deficiencies
  3. Start thiamine (vit B1) supplementation 100mg OD 5-7 days
  4. Initiate feeding at 40-50% of EER, slowly increase over next few days
  5. Continue to monitor electrolytes as feeding progresses, adjust amount of replacements as needed
22
Q

Should we replete blood sugar levels before initiating PN?-

A

No, PO/EN/PN/IV dextrose can precipitate or worsen refeeding

23
Q

What ethical principles are involved in making decisions regarding artificial nutrition?

A

These basic principles are (1) autonomy, respect the patient’s healthcare preferences; (2) beneficence, provide healthcare in the best interest of the patient; (3) nonmaleficence, do no harm; and (4) justice, provide all individuals a fair and appropriate distribution of healthcare resources.

4152 CA2 (6 decks)

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