Overview of Enteral Nutrition Flashcards
Describe the overall benefits of using enteral nutrition
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
List contraindications for enteral nutrition
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)
What factors should be included when choosing a feeding tube?
Expected duration of therapy
Desired feeding location (stomach or small bowel)
Administration mode (continuous vs bolus)
Expertise of clinicians available for feeding tube placement
What methods can be used for placement of long-term feeding tube?
Percutaneous endoscopy methods
Radiological methods using fluoroscopy, ultrasound, or CT
Open or laparoscopic
List the various potential signs and symptoms of refeeding
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)
List risk factors for aspiration
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
Define early EN initiation in the critically ill population
EN that is initiated with 24-48 hours of the initial insult (surgery, mechanical ventilation, neurological injury)
Burn patients may benefit from early EN initiation, within __ to __ hours of injury
4-6 hours
When are pump-assisted continuous drip infusions the preferred method for feeding patients?
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
Should initiation of EN be delayed in the absence of bowel sounds or movements?
No; delayed EN will increase the risk of compromising the GI mucosal barrier and immune function
How soon should EN be advanced to goal rate in stable noncritically ill patients?
Generally tolerate initially at the goal rate, should be advanced within 24-48 hours
Standard initiation and advancement protocols for noncritically ill patients?
Start full strength at 50 ml/hr and advance by 15 ml q 4 hours to goal rate
Standard initiation and advancement protocols for critically ill patients?
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
What are 2 EN volume-based protocols that have been shown to significantly improve nutrient delivery?
FEED ME (Feed Early Enteral Diet Adequately for Maximum Effect)
PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol)
When should EN initiation be delayed in the critically ill population?
When considered hemodynamically unstable (those with MAP <50 mmHg or starting vasopressor medication/require increasing doses to maintain BP). Rare complication of ischemic bowel
Factors that increase the risk for clogging a feeding tube?
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
2009 ASPEN EN practice guidelines for water flushes in feeding tubes?
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.
What is the purpose of providing water flushes through feeding tubes?
Maintain tube patency, provided to meet hydration needs especially if patient is not receiving IV hydration of drinking fluids
Tips regarding the form of a medication when given through enteral feeding tube
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
Tips regarding medication administration via the enteral feeding tube
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
Which EN delivery system is least likely to contribute to infection through bacterial contamination?
Closed system. Involves less manipulation and human/environmental contact with the EN formula and feeding sets
How can contamination of an EN formula occur?
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
Name some factors that can compromise the accuracy of gastric residual volume (GRV) checks
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
What other methods, aside from checking GRVs, should be used to assess GI function
Passage of flatus
Stool frequency and consistency
Physical examination to assess bowel sounds and abdominal girth
Abdominal radiographs
Describe conditions in which patients are at a high risk for dehydration
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)
Causes of hyperglycemia in hospitalized patients that aren’t related to diabetes
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.
Target blood sugar range per SCCM/ASPEN guidelines for hospitalized patients?
140-180 mg/dL
