Nutrition Support

Question 1

What are the indications for consideration for nutrition support?

Answer 1

BMI <18.5 kg/m2 and unintentional weight loss >10% over the last 3–6 months
BMI <20 kg/m2 and unintentional weight loss >5% over the last 3–6 months
At risk of malnutrition defined by any of the following:
Eaten little or nothing for >5 days and/or likely to eat little or nothing for the next 5 days or longer
Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs

Question 2

What is the preferred method of nutrition support?

Answer 2

Eating and drinking orally should always be the preferred method of nutrition support.

Question 3

When should clinically assisted nutrition and hydration be considered?

Answer 3

Clinically assisted nutrition and hydration should be considered for people who are malnourished or at risk of malnutrition and have inadequate or unsafe oral intake.

Question 4

What are the routes of nutrition support?

Answer 4

Oral
Enteral
Parenteral

Question 5

When should enteral tube feeding be considered?

Answer 5

Enteral tube feeding should be considered in patients with inadequate or unsafe oral intake, as long as they have a functional and accessible gastrointestinal tract.

Question 6

When should parenteral nutrition be considered?

Answer 6

Parenteral nutrition should only be considered in those with a non-functional, inaccessible, obstructed, or perforated gastrointestinal tract.

Question 7

When should oral nutrition support be considered?

Answer 7

Oral nutritional support should be considered for any patient with inadequate food and fluid intakes to meet requirements, unless they cannot swallow safely, have inadequate gastrointestinal function, or if no benefit is anticipated (e.g., end-of-life care).

Question 8

How can food be fortified for oral nutrition support?

Answer 8

Food can be fortified with protein, carbohydrate, and/or fat, along with vitamins and minerals.

Question 9

What are some strategies for oral nutrition support?

Answer 9

Snacks
Altered meal patterns
Practical help with eating
Finger foods
Coloured plates

Question 10

What are oral nutritional supplements?

Answer 10

Oral nutritional supplements are products designed to provide additional nutrients and calories when dietary intake is insufficient.

Question 11

Besides supplements, what else can be provided as part of oral nutrition support?

Answer 11

Oral nutrition support can also involve the provision of dietary advice to ensure optimal nutrient intake.

Question 12

When is the enteral route indicated?

Answer 12

The enteral route is indicated when oral intake is insufficient or unsafe. Some common indications include unconscious patients, neuromuscular swallowing disorders (e.g., stroke), physiological anorexia, upper gastrointestinal obstruction (e.g., head and neck tumors), gastrointestinal dysfunction or malabsorption (e.g., pancreatitis, GI dysmotility), increased nutritional requirements, psychological problems, and specific treatment (e.g., Crohn’s disease).

Question 13

What are the routes of enteral nutrition?

Answer 13

Directly into the stomach (gastric feeding) via orogastric, nasogastric, gastrostomy, or oesophagostomy tube.
After the stomach (post pyloric feeding) via nasoduodenal or nasojejunal tube, gastrojejunostomy, or jejunostomy.

Question 14

How long is Nasogastric (NG) feeding usually used for?

Answer 14

Nasogastric (NG) feeding is usually used for short-term feeding, typically less than 4 weeks.

Question 15

How is Nasogastric (NG) feeding administered?

Answer 15

Nasogastric (NG) feeding involves passing a tube through the nose and into the stomach via the esophagus.

Question 16

What is the risk associated with incorrect placement of the NG tube?

Answer 16

Deaths have occurred from incorrect placement of the NG tube and subsequent feeding. It is now considered a “never event.”

Question 17

What are some complications of NG feeding?

Answer 17

Sinusitis
Sore throat
Difficulty swallowing
Candidiasis (yeast infection)
Aspiration pneumonia
Displacement, blockage, and knotting are frequent complications.

Question 18

What is a gastrostomy?

Answer 18

A gastrostomy is the creation of an artificial tract between the stomach and abdominal surface.

Question 19

When is gastrostomy feeding typically used?

Answer 19

Gastrostomy feeding is usually used for long-term enteral support.

Question 20

How can a gastrostomy tube be placed?

Answer 20

A gastrostomy tube can be placed endoscopically, surgically, or radiologically.

Question 21

What do PEG and RIG commonly refer to in the context of gastrostomy?

Answer 21

PEG (percutaneous endoscopic gastrostomy) and RIG (radiologically inserted gastrostomy) describe the procedure of creating a gastrostomy, but they are also commonly used to describe the type of tube, which can lead to confusion.

Question 22

What are the two types of retention devices for gastrostomy tubes?

Answer 22

The two types of retention devices are a fixed internal retention device (disc-like bumper) or a fluid-filled balloon.

Question 23

What are the advantages of PEG tubes?

Answer 23

Can be performed as a day case procedure
High success rate
Quick procedure (~20 minutes)
General anesthesia is not needed
Low incidence of complications

Question 24

What are some contraindications for PEG tubes?

Answer 24

Severe obesity
Portal hypertension or esophageal varices
Coagulation abnormalities
Active gastric ulceration or malignancy
Total or partial gastrectomy
Ascites
Peritoneal dialysis
Tumor seeding

Question 25

What are some other considerations for PEG tubes

Answer 25

Chronic progressive neurological and neuromuscular disorders (e.g., motor neuron disease, dementia) should be considered in the decision-making process.

Question 26

What type of gastrostomy tubes are commonly used in radiological placement?

Answer 26

Balloon gastrostomy tubes are most commonly used in radiological placement.

Question 27

What are the advantages of radiological placement for gastrostomy tubes?

Answer 27

Very low risk of tumor seeding
Sedation is not required
Clear picture of anatomy allows for tube placement in difficult patients where endoscopic placement may have been unsuccessful.

Question 28

What are some complications of enteral feeding?

Answer 28

Refeeding syndrome
Aspiration (same risk as for NG and gastrostomy tubes)
Diarrhea (rarely attributable to the feed itself)
Tube blockage
Microbial contamination of the feed
Accidental tube removal (more common in NG tubes)
Stoma site problems (leakage, exit site infections, peritonitis, overgranulation)
Buried bumper syndrome

Question 29

What are the post-pyloric feeding routes that bypass the stomach?

Answer 29

Nasoduodenal or nasojejunal feeding routes bypass the stomach.

Question 30

What is the advantage of nasoduodenal or nasojejunal feeding?

Answer 30

Nasoduodenal or nasojejunal feeding overcomes the problem of gastroparesis and reduces the risk of subsequent aspiration, making it suitable for patients who lie flat or slide down the bed.

Question 31

What is gastrojejunostomy?

Answer 31

Gastrojejunostomy is a procedure where post-pyloric feeding access is obtained in patients with established gastrostomy access by inserting an extension device that threads through the existing gastrostomy lumen into the jejunum.

Question 32

What is jejunostomy?

Answer 32

Jejunostomy is a procedure where a stoma tract is created between the jejunum and abdominal surface, and a tube is placed surgically or radiologically. It is indicated for the need for post-pyloric feeding after major GI or hepatobiliary surgery or when there is an increased likelihood of gastric stasis. It may also be considered if gastrostomy feeding has failed, serving as a long-term option for jejunal feeding.

Question 33

What are the two methods of enteral feeding administration?

Answer 33

Pump feeding: Feed and/or water pumped through the tube at a continuous rate for a set number of hours.
Bolus feeding: Amounts of feed given by syringe through the tube on a number of occasions during the day.

Question 34

Why is water flushing vital in enteral feeding?

Answer 34

Water flushing is vital to prevent the tube from blocking.

Question 35

What is parenteral nutrition (PN)?

Answer 35

Parenteral nutrition is the delivery of nutrients into a vein.

Question 36

When should parenteral nutrition be used?

Answer 36

Parenteral nutrition should only be used when the enteral route is inaccessible or inadequate. Some common indications include major gastrointestinal surgery, enterocutaneous fistulae, gastrointestinal obstruction, prolonged postoperative ileus, severe malabsorption, severe mucositis following chemotherapy, and multi-organ failure.

Question 37

What are some risks associated with parenteral nutrition (PN)?

Answer 37

Catheter-related infections
Deficiencies and excesses of fluid and nutrients
Electrolyte disturbances
Liver dysfunction
Hyperglycemia and hyperlipidemia
Cardiac failure
Insertion-related complications (e.g., pneumothorax or haemothorax, thrombosis, cardiac arrhythmias, or nerve injury)
Longer-term risks (e.g., thrombus, catheter occlusion, catheter fracture, thrombophlebitis, extravasation)
PN must be administered appropriately and monitored closely.

Question 38

How is parenteral nutrition initially administered?

Answer 38

Parenteral nutrition is initially administered continuously over 24 hours via a pump.

Question 39

What are some aspects of PN monitoring?

Answer 39

Observations, including temperature, should be monitored every 4 hours.
Blood glucose levels should be monitored every 4 hours.
Daily monitoring should include urea and electrolytes, magnesium, calcium, phosphate, liver function tests, and full blood count.
Line inspection and weight should also be monitored.

Question 40

What is refeeding syndrome?

Answer 40

Refeeding syndrome refers to the metabolic and physiological consequences of the depletion, repletion, compartmental shifts, and interrelationships of various elements such as phosphate, potassium, magnesium, glucose, metabolism, vitamin deficiency, and fluid restriction.

Question 41

How can refeeding syndrome be defined?

Answer 41

Refeeding syndrome can also be defined as severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally.

Question 42

What are the triggers for refeeding syndrome?

Answer 42

Switch from fat to carbohydrate metabolism
Increased insulin release
Increased uptake of glucose, phosphate, potassium, magnesium, and water into cells
Synthesis of lean tissue

Question 43

What are the consequences of refeeding syndrome?

Answer 43

Refeeding syndrome can lead to fluid retention and low serum levels of potassium, magnesium, and phosphate.

Question 44

In which feeding routes is refeeding syndrome less likely to occur?

Answer 44

Refeeding syndrome is less likely to occur if a person is eating orally as the intake is usually self-limiting.

Question 45

What are the high-risk factors for refeeding syndrome?

Answer 45

Very little or no food intake for more than 5 days, especially if BMI is less than 20 kg/m2 with unintentional weight loss of more than 5% in the last 3-6 months.

Question 46

What are the very high-risk factors for refeeding syndrome?

Answer 46

BMI less than 16 kg/m2
Unintentional weight loss of more than 15% in the last 3-6 months
Very little or no nutrition for more than 10 days
Low levels of potassium, magnesium, or phosphate prior to feeding

Question 47

What are the additional risk factors for refeeding syndrome?

Answer 47

BMI less than 18.5
Unintentional weight loss of more than 10% in the last 3-6 months
Very little or no nutrition for more than 5 days
History of alcohol abuse or some drugs including insulin, chemotherapy, antacids, or diuretics

Question 48

How should nutrition be introduced to mitigate the risk of refeeding syndrome?

Answer 48

Start at 5-10 kcal/kg bodyweight or 50% of energy requirements depending on the risk.
Build up slowly.
Provide daily thiamine and a multivitamin.
Monitor bloods daily.
Give potassium, magnesium, and phosphate supplements as guided by biochemistry.

Question 49

What is Wernicke-Korsakoff’s syndrome (WKS)?

Answer 49

Wernicke-Korsakoff’s syndrome is a neurological disorder characterized by two phases: Wernicke’s encephalopathy and Korsakoff’s psychosis. These phases represent the acute and chronic stages of the same disease.

Question 50

What is the cause of Wernicke-Korsakoff’s syndrome?

Answer 50

Wernicke-Korsakoff’s syndrome is caused by an acute deficiency in the B vitamin thiamine (vitamin B1).

Question 51

How can Wernicke-Korsakoff’s syndrome be precipitated?

Answer 51

Wernicke-Korsakoff’s syndrome can be precipitated by providing calories in the absence of sufficient reserves of thiamine. This can occur during refeeding.

Question 52

Who is most frequently affected by Wernicke-Korsakoff’s syndrome?

Answer 52

Wernicke-Korsakoff’s syndrome is most frequently encountered in alcoholics.

Question 53

What are some symptoms of Wernicke-Korsakoff’s syndrome?

Answer 53

Wernicke-Korsakoff’s syndrome can lead to symptoms resembling dementia.

Question 54

How can Wernicke-Korsakoff’s syndrome be prevented?

Answer 54

Prophylactic thiamine should be given as per the guidance for refeeding syndrome to help prevent Wernicke-Korsakoff’s syndrome.

Question 55

What are the consequences of withholding nutrition?

Answer 55

Withholding nutrition and hydration can lead to death, with death occurring within up to 10 weeks without nutrition and 3-14 days if hydration is also withdrawn.
While giving hydration may seem humane, it can prolong dying and exacerbate symptoms.
Rapid death from dehydration can occur if clinically assisted nutrition is withdrawn or withheld, unless an alternative route for hydration is used.
Presence of cancer, systemic inflammation, advanced AIDS, or end-stage dementia may limit the benefits of any food given due to adverse metabolic changes often caused by cytokine-induced catabolism.

Question 56

What considerations should be made towards the end of life?

Answer 56

A person’s desire for food and drink may lessen.
Good mouth care is very important.
The appropriateness of continuing enteral and/or parenteral nutrition support should be considered.
The discontinuation of intravenous fluids must also be considered.
Clear reasons should be identified and recorded for the withdrawal of nutrition and hydration.
Compassionate care for the patient and ongoing support for relatives should be provided.
Some patients with capacity may choose to stop eating and drinking, and their decision should be respected with appropriate support for staff.

Question 57

How does dementia affect feeding?

Answer 57

Patients with dementia may eat less, lose weight, and experience swallowing difficulties, especially in the end phase of the disease.
The focus should be on the quality of life rather than the length of life according to the Alzheimer’s Society.
Gastrostomy feeding in advanced dementia should only occur in exceptional circumstances.
It is important to investigate why the patient has stopped swallowing or eating in practice.

Question 58

What is risk feeding?

Answer 58

Risk feeding refers to individuals who continue to eat and drink orally despite a perceived risk of choking or aspiration.

Question 59

In what situations does risk feeding occur?

Answer 59

Risk feeding may occur in various situations, such as when someone with capacity makes a decision to eat and drink despite the risk, when clinically assisted nutrition and hydration is not appropriate or declined, or when the benefits of eating and drinking orally outweigh the associated risks.

Question 60

Is there a moral difference between withholding and withdrawing treatment?

Answer 60

There is no intrinsic moral difference between withholding and withdrawing treatment.

Question 61

What may be emotionally more difficult for the healthcare team and those close to the patient?

Answer 61

It may be emotionally more difficult for the healthcare team and those close to the patient to withdraw a treatment from a patient rather than deciding not to provide it in the first place.

Question 62

Is there an ethical or legal obligation to provide a treatment that is not in the best interests of the patient?

Answer 62

Where a treatment is not in the best interests of the patient, there is no ethical or legal obligation to provide it, and therefore no need to distinguish between not starting the treatment and withdrawing it.

Question 63

How can the expectations and emotions of staff, patients, and relatives be managed during withdrawal of treatment?

Answer 63

Characterizing the treatment as being on trial for a fixed period of time with pre-defined criteria of success and failure can help manage the expectations and emotions of staff, patients, and relatives around withdrawal.