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CRS2 > Nutrition of the emergency and critical care patient > Flashcards

Nutrition of the emergency and critical care patient Flashcards

1
Q

Why is nutrition so important in critical patients?

A
  • Being sick is a metabolically active process
  • GIT becomes leaky and leads to bacterial translocation if not functioning properly
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2
Q

Which patients are classed as high risk following a nutritional assessment?

A
  • Patients that have not consumed RER for 3-5days
    • E.g. chronic renal failure
  • Weight loss of 10% adults (5% neonates) over similar time period
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3
Q

What nutritional considerations are there for a patient with hepatic encephalopathy?

A
  • Become protein intolerant
  • Meet calorie needs with low protein/appetising diet (the two things do not go together well necessarily)
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4
Q

Which is the preferred method of administering nutrition to critical patients?

A

Enteral feeding (as far rostrally as possible)

Note: either route (parenteral or enteral) requires a haemodynamically stable patient (especially enteral) with minimal acid-base and electrolyte derangements

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5
Q

Physiological benefits of enteral feeding?

A
  • Prevent intestinal villous atrophy
  • Maintains intestinal mucosal integrity
  • Decreases risk of bacterial translocation
  • Preserves GI immunological function
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6
Q

Contra-indications to enteral therapy?

A
  • Uncontrolled vomiting
  • GI obstruction
  • Ileus
  • Malabsorption
  • Maldigestion
  • Inability to protect the airway
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7
Q

Which anti-emetic drugs can be used to prevent nausea?

A

Combination of maropitant and metoclopramide combinations can work very well for dogs and cats

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8
Q

Options for enteral feeding tubes?

A
  • Naso-oesophageal
  • Naso-gastric
  • Oesophagostomy
  • Gastrostomy
  • Jejunostomy
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9
Q

How should naso-oesophageal or nasogastric tubes be used?

A
  • LA or light sedation
  • Limited to liquids
  • Short term
    • 7-14dd
    • Irritating
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10
Q

Contraindications for naso-oesophageal or nasogastric tubes?

A
  • Facial trauma
  • Respiratory disease
  • Excess sneezing or vomiting
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11
Q

Complications of naso-oesophageal or nasogastric tubes?

A
  • Epistaxis
  • Rhinitis
  • Sinusitis
  • Dacryocystitis
  • Inadvertent placement and dislodgement
  • Oesophageal irritation
  • Reflux
  • Blocked tube
  • Aspiration pneumonia
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12
Q

Where are oesophagostomy tubes placed?

A
  • Proximal oesophagus at mid-cervical level
    • Tip in distal oesophagus
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13
Q

Benefits of oesophagostomy tubes?

A
  • Well tolerated
  • Can leave them in for weeks to months
  • Wider selection of diets
    • Blenderised canned diets
  • Suitable for those with facial and oral disease
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14
Q

Risks and complications of oesophagostomy tubes?

A
  • Risks
    • Placed into airway or mediastinum
    • Damage to vessels and nerves in Ce
  • Complications
    • Cellulitis and infection at site
    • Dislodgement – patient, vomiting, regurgitation
    • Oesophageal irritation and reflux
    • Blocked tube
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15
Q

How is a gastrotomy tube placed?

A
  • Surgery
    • Laparotomy
  • Endoscopy
    • Can visualise placement
    • Reduced iatrogenic risk to other viscera
  • Blind technique
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16
Q

How quickly can gastrotomy tubes be used?

A
  • Cannot be used for 24 hours
    • Return of gastric motility
    • Fibrin seal
  • Leave in until stomach adhered to body wall
    • 10-14dd or longer
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17
Q

Benefits of gastrotomy tubes?

A
  • Well tolerated
  • Bolus feeding
  • Long-term home feeding
  • Wider selection of diets
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18
Q

Disadvantages of gastrotomy tubes?

A
  • Before using them have to leave them 24 hours so you get some fibrin development
  • Closer monitoring
  • More costly
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19
Q

Risks of gastrotomy tubes?

A
  • Cellulitis and infection at stoma site
  • Pyloric outflow obstruction if inappropriately placed
20
Q

Indications for jejunostomy tube?

A
  • Ideal for patients that can’t tolerate gastric feeding:
    • Gastroparesis
    • Uncontrolled vomiting
    • Pancreatitis
    • Cannot protect airway
21
Q

Period of use for jejunostomy tube?

A
  • Short period of use
    • Days to weeks
  • 24-48hrs until can use
22
Q

Placement of jejunostomy tube?

A
  • Laparotomy
    • Visualise tube, pexy bowel to body wall
    • Technically difficult to place
  • Transpyloric placement
    • Nasojejunal, gastrojejunal
    • Less invasive
    • A LOT of skill
23
Q

Disadvantages of jejunostomy tube?

A
  • Small tubes -Limits diet
  • More diligent monitoring
  • Mostly non-suitable for management at home
24
Q

Complications of jejunostomy tube?

A
  • A lot more than others
  • Peristomal cellulitis or infection
  • Peritonitis secondary to leakage
  • Retrograde migration of tube
  • Intestinal obstruction – tube migration
  • Clogging of tube
25
Q

Generally, how much should you feed with a critical patient?

A
  • Rest energy requirements (RER=70BW(kg)0.75)
  • Use for lean not obese body mass
  • Re-assess nutritional needs q12-24hrs
26
Q

Some conditions require more than RER, which conditions are these?

A
  • Sepsis
  • Head trauma
  • Burns
27
Q

If patients have prolonged anorexia, GI compromise or metabolic derangements how should they be managed nutritionally?

A
  • Caloric goal should be gradually increased over 3-5 days
    • If they have not been eating loads you do not want to overload them
  • Start at 30-50% RER goal
28
Q

Which conditions may require a lower fat diet?

A
  • Pancreatitis
  • Hyperlipidaemia
  • GI disease
29
Q

Complications of enteral feeding?

A
  • Usually minor
    • The main thing is going to be GI intolerance
    • Can include
      • Aspiration and pneumonia
      • Tube dislodgement
      • Metabolic abnormalities
30
Q

Non-patient complications of enteral feeding?

A
  • Obstructed tubes
  • Tube migration
31
Q

Routes of parenteral nutrition?

A

IV or IO

32
Q

Indications for parenteral nutrition?

A
  • For use when the enteral route is not feasible
    • Nausea and vomiting
    • Or other GI disease
    • Cannot protect the airway
  • Can be life sustaining
33
Q

Technical requirements for parenteral nutrition?

A
  • Aseptic vascular access
  • 24 hour nursing care
  • Point-of-care glucose monitoring (glucometers – most practices have these)
  • Formulation of PPN or TPN
    • Partial parenteral nutrition
    • Total parenteral nutrition
  • Vascular access
  • Measure blood glucose and regulate as required with insulin infusions
  • Catheters should be long-stay, dressed and re-dressed BID and examined frequently
  • Best delivered as a CRI
34
Q

Difference between partial parenteral nutrition and total parenteral nutrition?

A
  • PPN has glucose and protein
  • TPN has both plus lipid
35
Q

What other measures should be monitored when parenteral nutrition is being administered?

A
  • Electrolytes
  • BUN
  • Albumin
36
Q

Predisposing conditions to hyperglycaemia?

A

DM, Hyperadrenocorticism

37
Q

Predisposing conditions to lipaemia?

A

Pancreatitis, Idiopathic hyperlipidaemia, DM, Hyperadrenocorticism

38
Q

Predisposing conditions to azotaemia?

A

Renal failure

39
Q

Predisposing conditions to hyperammonaemia?

A

Hepatic failure, PSS

40
Q

Predisposing conditions to re-feeding syndrome?

A

Prolonged starvation or catabolic disease, DM

41
Q

Characteristics of re-feeding syndrome?

A

hypokalaemia, hypophosphataemia and hypomagnesaemia

42
Q

What % of calorie requirements should be protein in dogs and cats?

A
  • Dogs: 15-25% calories
  • Cats: 25-35% calories
43
Q

Why is parenteral feeding a good option for equine neonates with sepsis?

A

GI tract unable to cope with feeding and enteral feeding would lead to fatal C. difficile enterocolitis (normally fatal)

44
Q

How long should the parenteral nutrition formulation be used for and what does it do?

A
  • Maximum use 1-2 weeks
  • Don’t provide complete nutrition
    • Not trying to give them all the calories they need, just enough to prevent them to go into malnutrition
  • Provide energy, protein and water-soluble vitamins
45
Q

In which patients should parenteral nutritional formulation be used with care?

A
  • Care in patients with CHF, oliguria
    • Volume overload
46
Q

What are the practicalities of parenteral nutrition?

A
  • Start with 25-50% RER over first 12-24 hours and then increase by 25% every 8 hours up to 100% maximum
  • Use a clean giving set every day
  • Fluid pump
  • Always wear gloves when handling port
  • Don’t make more than is required for 24 hours
  • Protect the bag from sunlight if outdoors (Causes things to denature and become toxic)
  • Stop parenteral nutrition gradually
    • Pre-treat with glutamine (1-2g/kg)
    • Start enteral food gradually and build-up
    • Gradually decrease PN by 25% every 6 to 8hrs
47
Q

Complications of parenteral feeding?

A
  • Catheter issues
  • PN admixture
    • Microbial contamination
    • Precipitation
    • Drug-nutrient interactions
  • Metabolic
    • Re-feeding syndrome
    • Electrolyte abnormalities
      • Supplementation of fluids

CRS2 (64 decks)

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