Nutrition Support (PN vs. EN) Flashcards by Saniya Warwaruk

What are some conditions under which tube feeds may be necessary?

Swallowing problems/dysphagia

Nerve Disease

Trauma

Patient unconscious

Stroke - dysphagia/risk of aspiration

Severe burns - extreme hypermetabolism, unable to meet total needs through oral intake

Altered nutrient metabolism where requirements for specific macronutrients may be unique and cannot be met through diet alone

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What are contraindications to ENS? WHEN WOULD YOU NOT USE IT.

Expected need is less than 5-10 days for adults and 1-2 days for children - in these cases, try an oral strategy first. If they can at least eat their BMR so they don’t lose weight then stick to oral. If not able to eat BMR then tube feed UNLESS Crohn’s.

Severe acute pancreatitis - may feed carefully below Ligament of Trietz

High output proximal fistulas

Intractable Diarrhea or vomiting

Complete bowel obstruction - with partial obstructions, can feed distal to the obstruction carefully

Severe coagulopathy where risk for GI bleeding is high

Severe Portal hypertension

Abdominal wall infection

Massive Ascites

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What is dumping syndrome? What are symptoms of dumping syndrome?

When large amounts of partially digested food reach the small intestine - the food is hyperosmolar which draws water into the small bowel. If the fluid shift is at a rapid rate, it can draw the fluid from the brain. Avoid hyperosmolar formulas

Nausea
Weakness
Sweating
Palpitations
Diarrhea
Syncope

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How are Naso-enteral tubes placed?

Ng - gastric fluids
Nd - X-ray
Nj - X-ray

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What is the aspiration risk of Naso-tubes?

Ng - medium
Nd - low
Nj - low

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What is the dumping risk of Naso-enteral tubes?

Ng - medium if rate of feed is too high
Nd - medium if rate is too high or tube is moved
Nj - low

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What is the aspiration risk of G-tubes?

Gastrostomy: low to medium
Gj: low

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What is the dumping risk for G-tubes?

G: low
Gj: medium to high if high osmolarity formula administered

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What are indications for a Gastrostomy?

Esophageal obstruction, longer term feeding

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What are indications for a Gastro-jejunostomy?

Longer term feeding, high aspiration risk and severe delayed gastric emptying

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When is a jejunostomy tube used?

Inserted if there is a blockage at the pylorus which precludes the ability to insert a GJ tube. Tubes are placed surgically, are thinner and can break more readily. Medium to high dumping risk if high osmolarity formula is administered and low aspiration risk.

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What are the enteral feeding regimens?

Bolus feed - over 15-30 minutes
Intermittent - 1-2 hours
Continuous feeds > 2 hours

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Why would you require 15-30 minutes for a bolus feed?

Feeding by tube bypasses cranial nerves and thus there are no neuronal signals that signal digestion in the stomach. Want to take the time for digestion to be signalled.

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What are the advantages and disadvantages of each type of Enteral feeding regimen?

Bolus:
Advantage: short time, easy to administer, inexpensive
Disadvantage: potential GI intolerance

Continuous: Potentially increased GI tolerance, decreased risk of aspiration and gastric residual
Disadvantage: costly, requires pump and less freedom

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What are the gastrointestinal complications of tube feeding?

Nausea, Vomiting:
large gastric residuals
improper tube location
rapid infusion rate
hyperosmolar formula

Large Gastric Residuals:
Hyper osmolar formula
High fat content of formula
Gastroparesis

Diarrhea:
medication
lactose intolerance
nutrient malabsorption
Bacterial overgrowth
inadequate fibre
rapid infusion rate
hyperosmolar formula
hypoalbuminemia - low albumin = GI tract not working well, sloughing off protein into the GI tract

Constipation:
Dehydration
fecal impaction
obstruction
inadequate fibre
decreased activity
medications
intestinal dysmotility
Aging

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What are the metabolic complications of enteral feeding?

Dehydration: fever, infection inadequate fluid, excessive weight loss, drug therapy

Increased Serum Electrolytes: high content of formula, excess fluid losses, inadequate fluid intake, renal failure, drug therapy

Decreased Serum Electrolytes: excessive fluid intake, water retention, (SIADH = syndrome of inappropriate anti diuretic hormone), inadequate formula electrolytes, drug therapy

Hyperglycemia: metabolic stress, diabetes, excess glucose intake, drug therapy

Hypokalemia/Hypophosphatemia: refeeding syndrome, medications, excessive losses

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What is Lasix?

A common medication given to treat blood pressure that causes an increase of urine output, electrolyte status can then be impaired

What are the mechanical complications of tube feeds?

Clogged tube
Nasal Irritation/erosion
Tube displacement
Skin infections

Describe a standard enteral formula in terms of Calories and protein?

1 kcal/ml and 0.04g protein/ml

What is the relationship between particles and Osmolarity?

The greater the number of particles in a solution, the greater the osmolarity.
Smaller particle size = increased osmolarity

What is the relationship of individual macronutrients, electrolytes, and Osmolarity?

Carbohydrates:
If high molecular weight - large particles - Low osmolarity
If LMW - small particles - high osmolarity

Protein:
Large particles thus minimal effect
small amino acids - high osmolarity

Fats - do not form a solution in water thus minimal effect

Electrolytes:
Small particles - high osmolarity

When would you use a higher energy density enteral formula for an adult?

Typically for fluid restricted patients or patients with hypermetabolism - however higher osmolarity so may be harder to tolerate

What are the general guidelines for rate of tube feeds in new patients?

10-30mls/hour is the basic rule for brand new patients

What are the indications for use of parenteral nutrition?

Significant Bowel dysfunction resulting in inability to achieve adequate enteral nutrition for more than 7-10 days for adults, 4-5 days in children or 2-3 days in infants Hypermetabolism Moderate to severe pancreatitis requiring bowel rest of greater than 7 days Hemodynamic instability where high risk for mesenteric ischemia Severe dysmotility leading to a non-functioning GI tract

What are the contraindications for use of PN?

Gut is working Previously well nourished adults where GI is expected to be functional in 7-10 days Prognosis does not warrant aggressive nutrition support Vascular access is severely compromised

What conditions warrant cautious use of PN?

Severe hyperglycemia - requires slow initiation of dextrose Severe renal failure - more sensitive to protein, fluid and electrolytes Multi system organ failure - Severe metabolic acidosis or alkalosis Hyperosmolarity Severe electrolyte disturbances

What are the complications of parenteral nutrition?

Usually due to overfeeding and lack of GI stimulation Cholestatic liver disease - abnormal hepatic and biliary function and liver steatosis PN associated cholelithiasis Infection - gut atrophies between enterocytes or due to aseptic techniques PN induced liver disease

What are the risk factors in infants and children in developing PN induced liver disease?

Prematurity of birth duration of PN infection lack of enteral stimulation bacterial overgrowth overfeeding

What are the two routes of PN admission?

Central lines - can deliver more concentrated nutrition and goes into bigger veins Peripheral line - IV goes into smaller vein and can only give a small amount of nutrition

When would you use a central vs. peripheral line?

Peripheral lines (PIV) would be for less than 2 weeks - they are short term. Don't tolerate dextrose At most can give BMR Can only handle hypotonic or isoosmolar solutions used when patient is not fluid restricted Central lines (CVL) are for the long term Can last months or years can handle hypertonic solutions

What is a midline?

A peripheral IV access that can last up to two weeks

What is a portacatheter?

central line access device, located under the skin in the chest wall - often used when only need intermittent intravenous access

What are the device related complications of PN?

Infections Non infectious: catheter occlusions, thrombosis, breakage, phlebitis

What kind considerations should be used for pancreatitis?

Standard polymeric formula if tolerated Gastric feeding trialed first unless May need enzyme replacement therapy

What are general complications of enteral tube feeds?

Diarrhea - could be due to altered GI transit or change in gut microbiome, medications Constipation - related to hydration status or fiber Hyperglycemia micronutrient deficiencies refeeding syndrome Increased risk of aspiration

When would you use an elemental enteral formula?

Patients with short gut or Crohn's patients with severe exacerbations and serious malabsorption

What conditions would warrant cautious use of PN?

Severe Hyperglycemia - slow initation of dextrose Severe renal failre - careful with protein, fluid and electrolytes multi organ system failure - severe metabolic acidosis or alkalosis hyperosmolarity severe electrolyte disturbances - don't want to exacerbate the problem

What is cholestatic liver disease?

Cholestasis is the slowing or stalling of bile flow through your biliary system. It can be a problem in your liver or in your bile ducts

What is cholellithiasis?

Hardened deposits of digestive fluid that can form in your gallbladder

What can't a peripheral line tolerate?

Dextrose - collapses and leaks into the interstitial

When is a bolus feed appropriate?

No GI issues Hypermetabolic patients who can eat safely but need supplemental feedings Don't want to be tied to a pump but low risk of GI issues **New patients, in hospital always start with continuous

What is the optimal range of osmolarity for EN solutions?

Within 270-450 Most will tolerate between 270-330 really well