Nutrition support

Question 1

Reasons for unsuccessful oral nutrition

Answer 1

Unsafe swallowing for patient.

Patient is unable to eat despite oral nutrition supplements.

Question 2

Enteral feeding

• Mechanism
• Indications for use [4]

Answer 2

Nutrition fed through liquid into the gut

Only used if the gut is functioning:

• Unable to swallow
• Insufficient oral intake
• Unable to tolerate supplements
• Patient choice

Question 3

Para-enteral feeding

Answer 3

Fluid with nutrients given IV

Used when gut is not functioning:

• Aperistaltic
• Obstructed gut
• Gut is too short or damaged
• High fistula
• Gut is inaccessible

Question 4

Types of enteral access

Answer 4

Naso-gastric

Naso-jejunal

Percuntaneous endoscopic gastrostomy (PEG) / RIG (Radiologically insterted gastrostomy)

Percuntaneous jejunal (Jejunostomy/ PEJ/ RIJ)

Question 5

Advantages of NG feeds [5]

Answer 5

Physiological- uses the gut

Fast and easy to pass tube

Minimally invasive

Generally well tolerated

Easy to remove

Question 6

Indications of NG tube feeding

Answer 6

When the gut is still working

Stomach emptying

Short term feeding

Tube is accepted and tolerated by patient.

When it is safe to place tube and nose and oesophagus.

Question 7

Risks of NG

Answer 7

Misplaced/ blocked tube

Reflux/ aspiration

Not tolerated

Question 8

Naso-jejunal feeding advantages

Answer 8

Same as NG

Used for vomitting/ duodenal obstruction/ gastroparesis

Less likely to aspirate

Question 9

Naso-jejunal feeding risk

Answer 9

Technically difficult

Needs endoscopy or interventional radiology

Risk of misplacement

May not be tolerated

Question 10

PEG/ RIG

Answer 10

Percutaneous endoscopic gastrostomy / Radiologically inserted gastrostomy

Question 11

PEG/ RIG advantages [4]

Answer 11

Physiological

Durable: can last years

Least likely to be displaced

More comfortable and cosmetic

Question 12

Patients to use PEG/ RIG [5]

Answer 12

Has to have functioning gut

Has inability to swallowing food/ fluid

Condition must be irreversible or long-lasting.

Nutrition support is inappropiate

Can tolerate endoscopy

Question 13

PEG/ RIG risks

Answer 13

Perforation

Sepsis

Bleeding

Misplacement

Reflux

Death

Question 14

Percutaneous jejunal access advantages

Answer 14

Same as PEG

Tolerated in gastroparesis and dudodenal obstruction

Question 15

Percutaneous jejunal access risks

Answer 15

Higher risk of complications that PEG

Question 16

Contents of total parenteral nutrition

Answer 16

Fluid

Electrolytes

Amino acids

Lipids

Carbs

Vitamins and minerals

Question 17

Problems with TPN

Answer 17

Line access complications

Hyperglycaemia

Fluid/ electrolyte disturbance

Over/ underfeeding

Liver disease

Atrophy and inflammation of gut as it is not used.

Expensive

Question 18

Monitoring TPN

Answer 18

Checked every 4 hours

Checked daily for: line inspection, weight, LFT, FBC

Checked monthly for: micronutrients and TGs

Question 19

Re-feeding syndrome

Answer 19

Severe electrolyte + fluid shifts due to metabolic abnormalities in malnourished patients that are re-fed.

During starvation, protein pumps are inactivated.

• Causes Na+ and water to shift intra-cellularly
• K+ and phosphate shift extracellular

K+ and phosphate excreted.

Increase in energy causes sudden drop in plasma K and phosphate but rise in Na+ and H2O.

Question 20

Avoiding re-feeding

Answer 20

Replace electrolytes before feeding

Slow feeding- 5-10 calories per Kg of weight

Monitor electrolytes

Question 21

Wernicke-korsakoff’s syndrome

Answer 21

Wernicke= encephalopaty
Korsakoff= psychosis

Caused by thiamine deficiency
- Seen frequently in alcoholics

Question 22

Treating/ avoiding Wernicke-Korsakoff

Answer 22

Replace thiamine before and during re-feeding

low risk= high dose oral thiamine

high risk= IV Pabrinex

Question 23

PEG benefit in end stage dementia

Answer 23

Allows medication to be given

Allows maintenance of weight but:

• Doesn’t improve daily activities
• Does improve life expectancy