Nutritional Support Flashcards
Enteral Access
Route of access: nasal vs percutaneous
Where the feed is being delivered: gastric vs jejunal
How was the access put in: endoscopic vs interventional radiology
Nasogastric tube feeding
Advantages: uses the gut, fast and easy to pass tube, minimally invasive, well tolerated, easy to remove if not tolerated
Suitable for: working gut, stomach emptying, short term feeding
Risks: tube misplaced/blocked, reflux/aspiration, not tolerated
Confirming correct placement: CXR - remain in midline down to diaphragm, should bisect the carina, clearly visible below diaphragm
Nato-jejunal feeding
Advantages: same as for NG feeding + minimally invasive, less likely to aspirate/get misplaced, used for vomiting, gastroparesis, duodenal obstruction
Risks: technically difficult, usually needs endoscopy or placement in interventional radiology - delay in feeding, risk of misplacement, may not be tolerated
Percutaneous endoscopic gastrostomy or Radiologically inserted gastrostomy
Advantages: uses gut, durable - lasts a couple years, unlikely to be displaced, no tube in throat/on face
Suitable for patients with: functioning gut, inability to swallow adequate food/fluid, due to irreversible or long lasting cause, in whom nutrition support is thought to be appropriate, who can tolerate endoscopy or minimally invasive surgery
Risks: perforation, sepsis, misplacement, reflux, death, buried bumber, bleeding; not involved in mealtimes, attached to a pump 20 hours a day, alteration in body image
Percutaneous jejunal access
Surgical jejumostomy/PEJ/RIJ
Advantages: as for PEG + tolerated if gastroparesis/duodenal obstruction
Risks: as for PEG, but higher risk of complication due to position/anatomy; hence existence of PEG-J - a peg with an extension into the jejunum
Total Parenteral Nutrition
Fluid,, electrolytes, protein, fats, carbs, vitamins and minerals
Problems: line access complications (misplaced, extravasation of TPN, clot on line infection), hyperglycaemia/fluid or electrolyte disturbance, over or underfeeding, liver disease, gut not being used (atrophy & inflammation), expensive
Monitoring: 4 hours (observations inc temp and blood glucose), daily (U&E, Mg, Ca, phos, LFT, FBC, line inspection, weight) monthly (micronutrients and triglyceride)
Refeeding Syndrome
Severe electrolyte and fluid shifts, associated with metabolic abnormalities, in malnourished patients, undergoing refeeding.
During starvation, energy is saved by switching off transmembrane pumps; Na and water drift inter cellularly, K and phosphate drift extracellularly and are excreted to keep plasma levels stable (total body depletion)
As soon as you get energy, these are all switched back on and the sudden drop in plasma K and phos = arrhythmias and surge in Na and water = overload
How to avoid/treat refeeding
Be aware of risk Check electrolytes Begin replacement before feeding Start slow and build up Keep monitoring electrolytes daily and replacing as necessary
Wernicke-Korsakoff’s Syndrome
Neurological disorder
Wernicke’s encephalopathy and Korsakoff’s psychosis are the acute and chronic phases, respectively of the same disease
Caused by deficiency in the B vitamin thiamine and is most frequently encountered in alcoholics
Precipitated by providing calories in the absence of sufficient reserves of thiamine
Wernicke’s
Opthalmoplegia, unsteady gait, mystagmus, confusion
Reversible – but only if you act very quickly to give IV thiamine
Korsakoff’s psychosis
sudden onset, dramatic, irreversible memory loss, confabulation
How to avoid or treat
Be aware of risk
Replace thiamine before and during refeeding
If low risk and able to eat use high dose oral thiamine
If high risk or not eating then use IV Pabrinex
