Routes Of Feeding

Question 1

Why do we feed people? Consequences of malnutrition

Answer 1

1) physical: reduced FFM and strength, increased risk of pressure sores, reduced mobility, increased risk of infections
2) patho/physiological: impaired immune and organ function, increased risk of side effects and malabsorption
3) psychological: apathy and depression, reduced QoL, poor memory

Question 2

Screening risk using the MUST tool and dietetic assessment (ABCDE)

Answer 2

• BMI less than 18.5 suggests at a significant risk of malnutrition
• a history of recent weight loss: 10% loss in last 3-6 months unintentionally puts at high risk. Often working with an estimation of this, ie clothes and jewellery feeling baggier
• an acute disease effect: associated with being acutely ill and unable to eat for more than 5 days
• dietetic assessment: Anthropometry (weight and weight history), Biochemical (hydration status, deficiencies, refeeding), Clinical (disease states changing requirements), Dietary (diaries, ONS, any special diet required), Environment (facilities, family/carer issues)
• need to then identify the requirements, the diagnosis (in a PASS statement), aim of the treatment, and plan/goals (SMART)

Question 3

Normal fluid/electrolyte requirements

Answer 3

• nitrogen: 0.18g/kg/day
• fluid: 35 mL/kg/day
• electrolytes: sodium 1-2 mmol/kg/day, potassium 1mmol/kg/day, calcium and magnesium 0.075-0.15 mmol/kg/day, phosphate 0.15-0.3 mmol/kg/day

Question 4

Refeeding syndrome (who is at risk, why does it occur and how to treat)

Answer 4

• potentially fatal shift in electrolytes following movement from catabolic to anabolic state
• treat if BMI <16, havent eaten for 10+ days, low levels of P/K/Mg before feeding, unintentional weight loss of >15% in last 3-6 months. Or if have 2 of following: any of the 3 aspects of MUST assessment, history of drug/alcohol misuse (including insulin, chemotherapy, antacids, diuretics)
• caused by a movement of fat catabolism to anabolic state using exogeneous CHO
• treatment: start feeding slowly on 10 kcal/kg/day increasing slowly to daily allowance by 4-7 days, and provide Pabrinex IV during first 10 days of feeding, provide oral, enteral or IV phosphate, potassium and magnesium

Question 5

Enteral nutrition routes (ONS, NG, PEG, RIG, jejunostomy, complications)

Answer 5

• general rule with feeding is, if the gut works, use it (functional and accessible GI tract)
• complications of EN: nasal damage, inappropriate placement, bleeding, colonic perforation, aspiration, can cause nausea, bloating, RFS, hyperglycaemia
• ONS: 1-2 kcal/mL, can be given as standard, energy supplements, fat supplements or elemental feeds (crohn’s)
• NG tube: used if <30 days, syringe stomach aspirate to see if in right place (pH 5.5) or use x-ray, and can be placed at bedside, a misplaced NGT is a never event. Should be used for those with increased nutritional requirements, swallowing disorders (neuromuscular), unconscious patients. SHOULD NOT be used for those with skull fractures, nasal/facial injury or surgery, post op patients following upper GI surgery
• gastrostomy tube, PEG: hole in the stomach and tube inserted. Used for if going to be on EN for >1 month and swallowing prognosis is not good, may also be better if patient prone to pulling out (uses bumper disc- but can cause problem if flesh grows over it)
• gastrostomy tube, RIG: tube goes into stomach but held in place by an inflated balloon, which is easier to replace (so more common in community), placed in radiology.
• jejunostomy: tube goes straight into jejunum from outside, used for those with upper GI surgery (ie if oesophageal cancer an pulled stomach up to act as oesophagus)
• gastrostomy tubes need to be rotated to stop growing over it
• common site problems: infection and blocking of tube

Question 6

Use of parental nutrition

Answer 6

• nutrition through IV catheter in peripheral or central vein
• reserved for patients with nonfunctioning GI tract
• many be used for short bowel syndrome or intestinal dysmobility, prolonged bowel obstruction
• can use a peripheral cannula for TEMPORARY feeding (<7 days)
• medium to long term (7-28 days): PICC line for minimal IV infusions or medications
• long term (>28 days) feeding: Hickmann line, for home PN
• lots of care needed for these central lines and will be monitored closely by ward nurses
• infection/sepsis of the line site is life threatening therefore important that it is flushed and checked regularly
• can get cannula damage and thrombotic complications
• can also get some metabolic complications too: hypo/hyperglycaemia, electrolyte disturbance, liver dysfunction, metabolic bone disease
• psychological considerations: depression is common and urge to eat can be very strong