Overview of Enteral Nutrition

Question 1

Describe the overall benefits of using enteral nutrition

Answer 1

Helps maintain the functional integrity of the gut
Promotes efficient nutrient utilization
Reduces the risk of cholecystitis by ensuring release of cholecystokinin with the presence of nutrients in the small bowel
Luminal nutrients provide GI structural support and help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function
Reduces infectious complications associated with pneumonia, sepsis, IV line sepsis, and intra-abdominal abscess
Less expensive than PN

Question 2

List contraindications for enteral nutrition

Answer 2

Severe short bowel syndrome (<100-150 cm remaining small bowel w/o colon or 50-70 cm small bowel w/ colon)
Other severe malabsorptive conditions
Severe GI bleed
Distal high-output GI fistula
Paralytic ileus
Intractable vomiting and/or diarrhea that does not improve with medical management
Inoperable mechanical obstruction
When the GI tract cannot be accessed (when upper GI obstructions prevent feeding tube placement)

Question 3

What factors should be included when choosing a feeding tube?

Answer 3

Expected duration of therapy
Desired feeding location (stomach or small bowel)
Administration mode (continuous vs bolus)
Expertise of clinicians available for feeding tube placement

Question 4

What methods can be used for placement of long-term feeding tube?

Answer 4

Percutaneous endoscopy methods
Radiological methods using fluoroscopy, ultrasound, or CT
Open or laparoscopic

Question 5

List the various potential signs and symptoms of refeeding

Answer 5

Electrolyte abnormalities (hypophosphatemia, hypokalemia, hypomagnesemia, hypocalcemia, hyponatremia)
Cardiovascular conditions (arrhythmias, hypotension, heart failure, cardiac arrest)
Thiamin deficiency
Fluid retention
Hyperglycemia
Neurologic conditions (weakness, numbness, paresthesia, myalgia, vertigo)
Respiratory conditions (shortness of breath, pulmonary edema, respiratory failure)

Question 6

List risk factors for aspiration

Answer 6

Inability to protect the airway related to: reduced level of consciousness, neurologic deficit
Delayed gastric emptying related to: gastroparesis, medications (opioids), hyperglycemia, electrolyte abnormalities
Presence of naso- or oroenteric feeding tube
GERD
Supine position
Vomiting
Bolus enteral feeding
Mechanical ventilation
Age >70 years
Transport outside the ICU
Inadequate nurse-to-patient ratio
Poor oral care

Question 7

Define early EN initiation in the critically ill population

Answer 7

EN that is initiated with 24-48 hours of the initial insult (surgery, mechanical ventilation, neurological injury)

Question 8

Burn patients may benefit from early EN initiation, within __ to __ hours of injury

Answer 8

4-6 hours

Question 9

When are pump-assisted continuous drip infusions the preferred method for feeding patients?

Answer 9

Critical illness, mechanically vented using an oro-tracheal method, at risk for refeeding syndrome, poor glycemic control, fed via jejunostomy, demonstrated intolerance to intermittent gravity drip or bolus feed

Question 10

Should initiation of EN be delayed in the absence of bowel sounds or movements?

Answer 10

No; delayed EN will increase the risk of compromising the GI mucosal barrier and immune function

Question 11

How soon should EN be advanced to goal rate in stable noncritically ill patients?

Answer 11

Generally tolerate initially at the goal rate, should be advanced within 24-48 hours

Question 12

Standard initiation and advancement protocols for noncritically ill patients?

Answer 12

Start full strength at 50 ml/hr and advance by 15 ml q 4 hours to goal rate

Question 13

Standard initiation and advancement protocols for critically ill patients?

Answer 13

Start at 10-40 ml/hr and advance by 10-20 ml q 8 or 12 hours. However, many critically ill patients can tolerate rapid advancement of EN to goal rate within 24-48 hours, which results in smaller energy and protein deficits

Question 14

What are 2 EN volume-based protocols that have been shown to significantly improve nutrient delivery?

Answer 14

FEED ME (Feed Early Enteral Diet Adequately for Maximum Effect)
PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol)

Question 15

When should EN initiation be delayed in the critically ill population?

Answer 15

When considered hemodynamically unstable (those with MAP <50 mmHg or starting vasopressor medication/require increasing doses to maintain BP). Rare complication of ischemic bowel

Question 16

Factors that increase the risk for clogging a feeding tube?

Answer 16

Not flushing the tube with water, fiber-containing formulas, use of small-diameter tubes, use of silicone rather than polyurethane tubes, checking gastric residual volumes, and improper medication administration via the tube

Question 17

2009 ASPEN EN practice guidelines for water flushes in feeding tubes?

Answer 17

Recommend flushing feeding tubes with at least 30 ml of water every 4 hours during continuous feeding or before and after intermittent or bolus feeding in adult patients. Should also be flushed with 30 ml of water after gastric residual checks.

Question 18

What is the purpose of providing water flushes through feeding tubes?

Answer 18

Maintain tube patency, provided to meet hydration needs especially if patient is not receiving IV hydration of drinking fluids

Question 19

Tips regarding the form of a medication when given through enteral feeding tube

Answer 19

Use liquid or suspension forms when possible (liquid meds may contain sorbitol or be hyperosmotic, which can lead to diarrhea; if diarrhea occurs, an alternate medication regimen may be needed)
If tablet form must be used, consult with pharmacist to ensure it can be safely crushed and dispersed in water prior to administration.
Enteric-coated, sublingual, or sustained release tablets generally should NOT be crushed
Confirm appropriate medication delivery route with pharmacist. Medications that depend on gastric acid for breakdown or absorption may need to be substituted or given by alternate method if feeding tube is in duodenum or jejunum

Question 20

Tips regarding medication administration via the enteral feeding tube

Answer 20

Stop EN prior to the administration of meds; restart ASAP, only delay restarting EN when it is necessary to avoid altered drug bioavailability
Flush tube w/ at least 30 ml water before and after giving meds through tube
Give each med separately and flush tube w/ 5 ml warm water btwn meds
Do not mix meds or dosage forms, can affect drug stability and efficacy
If tube is smaller than 12 Fr, avoid using it to give crushed meds, if possible
Do not add meds to EN formula. This could increase incidence of tube occlusions, interfere with medication and nutrient bioavailability, affect GI function, and increase risk of microbial contamination

Question 21

Which EN delivery system is least likely to contribute to infection through bacterial contamination?

Answer 21

Closed system. Involves less manipulation and human/environmental contact with the EN formula and feeding sets

Question 22

How can contamination of an EN formula occur?

Answer 22

During preparation if additional modular components must be added to the formula
When feeding is transferred to the administration container
During assembly of the feeding system
During administration to the patient
Improper hand washing

Question 23

Name some factors that can compromise the accuracy of gastric residual volume (GRV) checks

Answer 23

Feeding tube type, diameter, and position
Viscosity of the GRVs
Technique, including size of the syringe and time and effort spent
Position of the patient

Question 24

What other methods, aside from checking GRVs, should be used to assess GI function

Answer 24

Passage of flatus
Stool frequency and consistency
Physical examination to assess bowel sounds and abdominal girth
Abdominal radiographs

Question 25

Describe conditions in which patients are at a high risk for dehydration

Answer 25

Those with increased fluid losses, high GI volume output
Diarrhea, colostomies, ileostomies, fistulas
High fever, burns, extensive wounds
Highly osmolar enteral nutrition (osmotic diuresis related to an increased renal solute load)

Question 26

Causes of hyperglycemia in hospitalized patients that aren’t related to diabetes

Answer 26

Multifactorial, including increased release of counterregulatory hormones that stimulate gluconeogenesis , proinflammatory cytokines that result in insulin resistance, provision of steroid and adrenergic medications, and excess dextrose administration via IV fluid solutions and medications.

Question 27

Target blood sugar range per SCCM/ASPEN guidelines for hospitalized patients?

Answer 27

140-180 mg/dL