Nutritional Support Flashcards
What is the formula to calculate a patient’s recommended energy intake via the weight-based method?
Recommended energy intake = 25 - 35 kcal/kg body weight
What are the protein requirements for:
- Healthy adult
- Trauma/ surgery/ burn pts
- Sepsis/ critical illness
- CKD pt (not on dialysis, HD/PD, and CRRT)
- Healthy adult - 0.8 g/kg/day
- Trauma/ surgery/ burn pts: 1.5-2 g/kg/day
- Sepsis/ critical illness:1.5-2, up to 2.5 g/kg/day
- CKD pt
- Not on dialysis: 0.6-0.8 g/kg/day
- HD/PD: 1.2 g/kg/day
- CRRT: up to 2 g/kg/day
Name the 2 pre-pyloric tubes for enteral feeding
- Nasogastric (NG)
- Percutaneous Endoscopic Gastronomy (PEG)
Name the 2 post-pyloric tubes for enteral feeding
- Nasojejunal (NJ)
- Percutaneous Endoscopic Jejunostomy (PEJ)
What are some points to take note about pre-pyloric tubes for enteral feeding? (4)
- More physiologic (feeding into stomach mimics normal digestion)
- ↑ tolerance to bolus feeding (due to larger capacity of stomach)
- May be used for venting (prevents aspiration pneumonia)
- Not to be used for feeding in pts with delayed gastric emptying (due to risk of aspiration pneumonia)
What are some points to take note about post-pyloric tubes for enteral feeding? (4)
- Smaller bore, less discomfort (narrower tube lumen)
- Higher risk of tube clogging (due to narrower lumen)
- May be used in conditions that result in dysfunctionality of proximal GIT (bypasses stomach and duodenum)
- Minimises aspiration risk
What are the 4 types of EN formulas?
- Intact/ polymeric formulas
- Elemental/ semi-elemental formulas
- Modular formulas
- Immune-modulating/ disease-specific formulas
Give a brief overview of the characteristics of the 4 types of EN formulas
Intact/ polymeric formulas:
- for normal digestive processes, req sufficiently functional GIT
- some are concentrated for fluid-restricted pts
Elemental/ semi-elemental formulas:
- partially/ completely hydrolyzed nutrients
- for pts with impaired digestive capacity/ malabsorption
Modular formulas
- single nutrient
- to enhance specific nutritional component
Immune-modulating/ disease-specific formulas
- for specific populations of patients
- some polymeric feeds can also be disease-specific
Name the disease-specific feed marketed for diabetes, its caloric density, and main features
Diabetes: Glucerna
1 kcal/mL
Low glycemic index
Name the disease-specific feed marketed for increased energy and protein needs, its caloric density, and main features
Increased energy and protein needs: Fresubin protein energy
1.5 kcal/mL
High protein, 20g/ serving
Name the disease-specific feed marketed for CKD not on dialysis, its caloric density, and main features
CKD not on dialysis: Nepro LP
1.8 kcal/mL
Low protein, K, phosphate
Name the disease-specific feed marketed for CKD on dialysis, its caloric density, and main features
CKD on dialysis: Nepro HP
1.8 kcal/mL
High protein, 18g/ serving
Name the disease-specific feed marketed for inflammatory dieases/ cancer, its caloric density, and main features
Inflammatory dieases/ cancer: NutriFriend
1 kcal/mL
Contains omega-3 fatty acids EPA/DHA
What are the 3 types of drug-nutrient interaction?
- Binding of medication to tubes (e.g. PHT)
- Medication-feed interaction (eg. levothyroxine, bisphosphonates with calcium in feeds)
- Alteration of dosage form (crushing before inserting into tube alters dosage form of SR/ enteric coated drugs)
What are the 8 common complications of enteral feeding? (IDCIRCAH- “I Don’t Care, I Really Care About Him”)
- Refeeding syndrome
- Improper tube placement/ displacement
- Clogging
- Aspiration
- Infections
- Diarrhea
- Constipation
- Hypernatremia
Monitoring parameters for enteral feeding? (GWSBEF- Guys, Watch Some Body’s Enteral Feeding)
-Signs of intolerance (N/V/D)
-Gastric residual volume (not recommended)
-Blood glucose level (use diabetic feed if pt’s levels spike)
-Electrolytes (refeeding syndrome)
-Fluid balance (change to more caloric-dense feed if fluid restricted)
-Weight (signs of fluid overload)
What are 5 ways we can maximize tolerance to EN?
- Continuous, not bolus
- Use prokinetic agents (e.g. metoclopramide, domperidone, IV erythromycin)
- Post-pyloric feeding if intolerant to gastric feeding
- Isotonic formula (e.g. Boost Isocal)
- Semi-elemental/ elemental feeds for pts with malabsorptive issue (e.g. short bowel syndrome)
For parenteral nutrition, does the peripheral or central line allow for delivery of higher osmolarity solutions? And why?
Central line, as there is high blood flow which can dilute the infusions/ medications
Give a brief overview of all the components of a PN (macronutrients and micronutrients), and the calories in each macronutrient
Macronutrients:
- Amino acids (4 kcal/g)
- Dextrose (glucose) (3.4 kcal/g)
- Lipids (10 kcal/g)
Micronutrients
- Electrolytes
- Multivitamins
- Trace elements
What are the types of electrolytes (micronutrients) in PN?
-Ca, Mg, Na, K, Phos
-Acetate, chloride (as needed to maintain acid-base balance)
What are the types of multivitamins (micronutrients) in PN?
-Fat soluble (A, D, E, K)
-Water soluble (B, C)
What are the types of trace elements (micronutrients) in PN?
-Zinc, selenium, iron, iodine
-Copper, manganese
Is TPN usually given by central line or peripheral line?
Central line
What are 3 ways of prevention and mitigation for drug-nutrient interaction for PN?
- Administer IV drug via separate peripheral IV cannula (but would increase needle injuries, so if can do double/ multiple lumen PICC then do that instead)
- Double lumen PICC: usually no concerns with administering PN concurrently with other drugs (even if both Y-site incompatible)
- If need to administer via same IV line, pause PN, flush the line and administer the IV drug. Then flush again before resuming PN infusion (problem: IV drugs may take 1–2 hours to infuse, pausing PN for that long can cause pt to have hypoglycemia if pt is entirely dependent on PN for blood sugar levels (dextrose))
What are 3 device-related complications that can occur with PN?
- Occlusion in IV catheter: thrombosis/ clotting, inappropriate flushing techniques, ppt due to drug incompatibilities, crystallization, lipid residues (from TPN)
- Mal-positioning
- Catheter-related bloodstream infections
What are the 5 metabolic complications for PN? (RHFIM- Really Hungry Folks Infuse More)
- Refeeding syndrome
- Hyper/hypoglycemia
- Fluid overload
- Intestinal faliure associated liver disease (IFALD)
- Metabolic bone disease
What are the monitoring parameters for PN? (BEFWRLTI- Big Elephants Find Water Really Large, Thirsty, and Important)
-Blood glucose level
-Electrolytes (refeeding syndrome)
-Fluid balance
-Weight
-Renal function tests (creatinine, blood urea nitrogen, chloride/ CO2)
-Liver function tests (potential IFALD)
-Triglycerides
-Infection signs (e.g. differential blood count, fever, redness/pus around site of line access)
What are the electrolyte changes in refeeding syndrome?
Hypokalemia, hypomagnesemia, hypophosphatemia, thiamine deficiency, salt & water retention (edema)
Management strategies for refeeding syndrome?
- Identify high risk patients
- Check serum electrolytes at baseline
- Correct deficiencies prior to feeding, defer feeding if electrolytes are critically low
- Administer thiamine (Vit B1) supplement
- Initiate feeding slowly and gradually ↑ over next few days to meet nutritional req (start low, go slow!)
-> Can first provide < 50% of caloric req then ↑;
-> Max 10 kcal/kg/day - Continue to monitor electrolytes as feeding progresses, adjust amt of replacements as needed
What are the high risk patients for refeeding syndrome?
Patient has ONE of the following:
- BMI < 16 kg/m^2
- Unintentional weight loss > 15% in past 3-6 months
- Little/ no nutritional intake for > 10 days
- Low levels of K, Mg, Phosphate before feeding
Patient has ≥ 2 of the following:
- BMI < 18.5 kg/m^2
- Unintentional weight loss > 10% in past 3-6 months
- Little/ no nutritional intake for > 5 days
- Hx of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics
