Parenteral And Enteral Nutrition In Practice

Question 1

What is enteral nutrition?

Answer 1

This is any method of feeding that uses the GI tract to deliver nutrition and calories to a patient.
E.g.
1. Normal oral diet

2.feeding tubes into the GI tract:
-nasogastric (feeding through the nose)
-nasoduodenal (feeding through the nose into the duodenum)
-nasojejunal ( feeding through the nose, through the stomach and ends in the jujunum small intestine)
-gastrostomy (feeding through an external artificial external opening into the stomach)
-jujunostomy( feeding through external articulated external opening into the small intestine)

Question 2

What is parenteral nutrition?

Answer 2

This is the delivery of nutrition and calories Inuit the central or peripheral vein.
-total PN = all nutritional requirements are given
-partial PN = partial nutritional requirements are given

Question 3

Why is enteral nutrition proffered to parenteral nutrition ?

Answer 3

This is because eternal nutrition is:
-simpler and more convenient
-cheaper
-less complicated
-less risk of infection.
-more physiological (maintains the GI muscosal layer, helps to prevent ulcers and reduces the breakdown of muscles)

Question 4

What may obstruct the use of enteral nutrition?

Answer 4

Gut absorption issues e.g. obstruction, damage etc.

Nasogastric tube into the stomach needs to be fitted correctly in order to avoid aspiration.

Question 5

Why is enteral nutrition used ?

Answer 5

-strokes
-neurological conditions which impair swallowing
-after operations preformed on the face, neck,throat or stomach
-blockage of the oesophagus or stomach
-radiotherapy of the throat or gullet.

Question 6

What is the best way of feeding if the patient is unable to eat etc for a long time?

Answer 6

The best option would be GASTROSTOMY, thus is where an external tube is placed through the abdominal wall and directly into the stomach.

Question 7

How are medications given to people who are NIL BY MOUTH?

Answer 7

PEG - percutaneous endoscopic gastrostomy , this is where a tube is inserted into the skin and into the stomach wall.

NG- nasogastric tube, through the nose down to the stomach

Question 8

What must a pharmacist consider when giving a patient medication via a feeding tube?

Answer 8

They must consider:
-interactions
-compatibility
-stability

We want to ensure that the medication is getting to the patient in the most effective form.

Question 9

What is parenteral nutrition and what does it consist of?

Answer 9

This is a method of feeding that bypasses the GI tract. The solution that is given is nutrition solution that is administrated via IV.

Consists of:
-carbohydrates:60-70%
-fat: 30-40%
-protein:1g protein
-electrolytes
-minerals
-vitamins

Question 10

When should parenteral nutrition be considered?

Answer 10

-if a patient is severely malnourished
-at risk of malnourishment
-a BMI of less than 18.5
-unintentional weight loss greater than 10% within the last 3-6 months
- a BMI of less than 20 and unintentional weight loss greater than 5% in 3-6 months.
-have eaten kitten to nothing for more than 5 days
-have a port absorptive capacity
-have a high nutrient losses
-increased nutritional needs.
-obstructed GI tract

Question 11

In what types of infants can we use parenteral nutrition?

Answer 11

-prematurity
-GI tract abnormalities e.g. obstruction
-low birth weight children
-patients undergone major surgery
-IBD
-respiratory disease e.g. asthma
-sepsis
-burns
-major trauma
-difficulty digesting foods

Question 12

How is PN administrated?

Answer 12

Can be administrated by peripheral or central intravenous catheters. The solutions are different depending on where it is administrated from.

Question 13

Where is the catheter placed when it is done centrally?

Answer 13

A central line is longer with a larger tube and is placed in the large vein in the back of the neck,upper chest or groin.
This is usually preferred as it stays in place longer.

Question 14

What makes up the solution for peripheral PN?

Answer 14

Maximum glucose concentration is 10%
Maximum osmolality is 1210 mosmol/kg

Question 15

What makes up solution for central PN?

Answer 15

Theoretically can give ver high glucose concentrations although stay below 25%, a fast flowing blood supply can quickly dilute any solutions infused, making it less harmful to the surrounding tissue.

Question 16

How to initiate parenteral nutrition?

Answer 16

1.introduce it slowly and progressively and closely monitor the patient.

2.start off with no more than 50% of the patients needs for the first 24-48 hours.

3.the nutritional requirements are determined via a healthcare professional with all the relevant skills, thus can fully determine what the patient is missing.

4.trace elements should be added into the bag before using.

5. We don’t add drugs into the PN bags rather the central line tubes.

Question 17

When must a patient be stopped on PN?

Answer 17

They should be stopped on PN nutrition when the patient establishes on adequate oral support.

Question 18

What monitoring is done with Parenteral nutrition?

Answer 18

-body weight (undressed)
-height
-head circumference
THIS IS TO ASSESS GROWTH

Question 19

What complications can arise with PN?

Answer 19

-hyperglycaemia (this can be avoided by consistently checking the glucose plasma levels)
-hypoglycaemia
-re feeding syndrome (this appears when food is introduced too quickly after a period of malnourishment.
-hypertriglyceridemia
-mineral and electrolyte imbalances

Question 20

How can we ensure complication are caught early?

Answer 20

Close monitoring e.g. blood tests within the first week, this will essentially help with detecting metabolic complications and allow early corrections.

Question 21

What other monitoring is needed with PN?

Answer 21

LIPIDS AND TRIGLYCERIDES:
These levels are crucial to measure to determine the patients oxidative capacity for lipid metabolism.( the higher the number the better)

TRACE ELEMENTS AND VITMIN DEFICIENCIES:

HEPATIC DYSFUNCTION:
-check the liver routinely to ensure that there is detection of liver adverse effects.
-cholestasis is a recognised complication so therefore these regimes can be changed to reverse progression.

Question 22

What is re feeding syndrome ?

Answer 22

This relates to the potentially fatal shift in fluids and electrolytes that may occur in malnourished patients receiving articulate feeding.

It consists of:
-hypophosphatemia( this is a reduction int he amount of phosphorus that is found in the blood, which can lead to muscle weakness, heart problems etc.
-abnormal sodium and fluid balance
-changes in glucose, fats and protein metabolism
-hypokaelemia
-hypomagnesaemia

Question 23

What happens during the re feeding process?

Answer 23

Due to metabolic and hormonal changes caused by rapid initiation of re feeding after a period of under nutrition:

• semi starvation results in higher ketone levels which become main energy source, reduced gluconeogensis and depletion of intracellular minerals.

-during refeeding glycemic leads to increased insulin levels and decreased glucagon

-insulin stimulates glycogen fat and protein synthesis which requires minerals e.g. phosphate, magnesium and co factors such as thiamine

-insulin shifts potassium into cells, magnesium and PO4 also taken into the cells via osmosis.

-decreased serum levels of phosphate,potassium,magnesium, all of which are already depleted.

Question 24

What are the risk factors of refeeding syndrome?

Answer 24

-BMI less than 16
-unintentional weight loss greater than 15% within 3-6months
-little to no nutritional intake for more than 10 days
-low potassium,phosphate and magnesium levels prior to feeding

Patients with 2 or more of the following:
-BMI under 18.5
-unintentional weight loss of 10% within 3-6 months
-little to no nutritional intake for the last 5 days
-a history of alcohol abuse or drugs including insulin, chemo, antacids and diuretics

Question 25

What should be done if patients are at risk of re feeding syndrome?

Answer 25

People at risk of re feeding syndrome should be identified:
-daily blood tests
-weight taken daily after discharged
-supplements with vitamins and trace elements
-reintroduce calories slowly

E.g. 50% by day 1
75% by day 2
100% by day 3

Question 26

What are some other potential complications of PN?

Answer 26

Infection:
-catheter related sepsis
-systemic infection

Metabolic:
-glucose intolerance
-electrolyte disturbances
-acidosis (too much acid in the body)
-cholestasis (liver disease, reduced bile flow)

Administration:
-line access
-compatibility information

Question 27

What compatibility must the PN bags include?

Answer 27

PN bags may be standard or bespoke (depending on the patient weight and BMI these bags can be altered )
-PN must not be mixed

Question 28

What is the clinical pharmacist role in PN bags?

Answer 28

Total PN screening and calculations
Monitoring
Prescribing and clinical checking
Medications via feeding tubes (the pharmacist should be able to provide advice on which drugs are most appropriate)

Question 29

what is the job of the aseptic pharmacist?

Answer 29

TPN preparation and stability checks
Checking if the quality is good
Checking stability