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The alimentary system > What all doctors should know about nutrition > Flashcards

What all doctors should know about nutrition Flashcards

1
Q

How is feeding of social importance?

A 
A Basic requirement
Provides Nurture
Is Symbolic
Means “Caring”
Is a Social Binder
Confers psychological benefits
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2
Q

List the routes of nutritional support

A

Feeding first

Unless it is contraindicated

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3
Q

When may feeding be contraindicated?

A

Unsafe swallow

Damaged/non-functioning gut

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4
Q

What are the two methods used if feeding via food is unsuccessful?

A

Enteral

Parenteral

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5
Q

What is enteral feeding?

A

Using the gut

Nutritionally complete liquid feeds through various tubes which access the gut

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6
Q

What is parenteral feeding?

A

Bypassing the gut
Nutritionally complete liquid feed which is broken down – to glucose / amino acids / fats & engineered to be safely administered intravenously

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7
Q

When is parenteral feeding used?

A

If the gut is not functioning

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8
Q

Why might the gut not be functioning?

A 
Aperistaltic
Obstructed
Too short
Too damaged
High fistula
Inaccessible
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9
Q

Why might enteral feeding be necessary?

A 
The gut is functioning but 
Unable to swallow
Includes unconscious
Insufficient oral intake despite supplements
Unable to tolerate supplements
Patient choice
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10
Q

List the different types of enteral access

A

To make it easier:
All names are just descriptions of how we are getting food in:

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

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11
Q

What are the advantages of nasogastric tube feeding?

A

Uses the gut → physiological
Fast and easy to pass tube
Can be done at the bedside by most nursing staff
Minimally invasive
Generally well tolerated
Easy to remove if not tolerated / no longer required

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12
Q

Who is nasogastric tube feeding suitable for?

A

Working gut
Stomach emptying (into duodenum)
Safe to put tube through nose and down oesophagus
Patient must accept / tolerate the tube
Short-term feeding
e.g. whilst unconscious on ITU, post-op, post-stroke, acute illness

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13
Q

What are the risks of nasogastric feeding?

A 
Tube misplaced / displaced / blocked
 Reflux / aspiration
 Not tolerated
Tube itself or 
volume of feed infused
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14
Q

How is correct placement of a nasogastric tube confirmed?

A

The chest x-ray view should be adequate –upper oesophagus down to below the diaphragm
The NG tube should remainin the midline down to the level of the diaphragm
The NG tube shouldbisect the carina (T4)
The tip of the NG tube should be clearly visible and belowthe diaphragm
The tip of the NG tube should be several cm (10) beyond the GOJ to be confident that it’s within the stomach

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15
Q

What are the advantages of naso-jejunal feeding?

A

As for NG feeding plus
Vomiting / gastroparesis / duodenal obstruction
Minimally invasive – although may need x-ray or endoscopy to place
Less likely to aspirate / get misplaced

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16
Q

What are the risks of naso-jejunal feeding?

A 
Technically difficult
Generally needs endoscopy or placement in interventional radiology
This can create delay in feeding
Risk of mis/displacement
May still not be tolerated
17
Q

What do PEG and RIG stand for?

A

Percutaneous endoscopic gastrostomy (PEG) or Radiologically Inserted Gastrostomy (RIG)

18
Q

What are the advantages of a PEG?

A 
Uses the gut / physiological
Durable
Tubes last up to a couple of years
Unlikely to be accidentally displaced
No tube in throat / on face 
Comfort
Cosmetic
19
Q

Who are PEGs and RIGs suitable for?

A

Patients with:
a functioning gut
Inability to swallow adequate food/fluid
Due to an irreversible or long-lasting cause
In whom nutrition support is thought to be appropriate
Who can tolerate an endoscopy and minor surgical procedure

20
Q

What are the risks and shortcomings of a PEG or a RIG?

A 
Perforation
Sepsis (Peritonitis and skin infection)
Bleeding
Perforated viscous
Attached to a pump 20 hours per day
Misplacement
Reflux
Buried bumper
Death (6% at 30 days) 
Not involved in mealtimes 
Alteration in body image
21
Q

What are the advantages of a surgical jejunostomy (PEJ)?

A

As for PEG plus
Tolerated if gastroparesis/duodenal obstruction
i.e. longterm option for those requiring NJ feeding

22
Q

What are the risks of a surgical jejunostomy (PEJ)?

A

As for PEG but higher risk of complication due to position / anatomy of small bowel
Hence existence of PEG-J a PEG with an extension into the jejunum – best of both worlds

23
Q

What is contained in total parental nutrition?

A 
Fluid
Electrolytes
Protein – as amino acids
Fat
Carbohydrate
Vitamins
Minerals
24
Q

List some problems with TPN

A 
Line “access” complications
Misplaced line
Extravasation of TPN
Clot on the line (thromboembolism)
Line infection
Hyperglycaemia
Fluid / Electrolyte disturbance
Over or under-feeding
Liver disease
Gut not being used → atrophy and inflammation
£££££
25
Q

How is TPN monitored?

A

4 hourly: Observations including temperature and Blood glucose
Daily: U&E, Mg, Ca, phosphate, LFT, FBC, Line inspection and Weight
Monthly: Micronutrients, Triglyceride

26
Q

What is a refeeding syndrome?

A 
Refeeding syndrome is defined as 
severe electrolyte and fluid shifts 
associated with metabolic abnormalities 
in malnourished patients 
undergoing refeeding –

whether orally, enterally or parenterally.

27
Q

Describe the pathogenesis of refeeding syndromes

A

During starvation energy is saved by switching off trans-membrane pumps

Na (& water) drift intra-cellularly

K & Phos drift extra-cellularly (and are excreted to keep plasma levels stable) → total body depletion

As soon as you get any energy these are all switched back on immediately
→ sudden drop in plasma K and Phos → arrhythmias
→ sudden surge in plasma Na and water → overload

28
Q

How can refeeding syndromes be avoided?

A 
Be aware of the risk
Check electrolytes (Na, K, Mg, Ca, Phos)
Begin replacement before feeding
Rule of thumb: start slow and build up
As low as 5-10kcal/kg/24hrs
Keep monitoring electrolytes daily (!) and replacing as necessary
29
Q

Define Wernicke-Korsakoff’s syndrome

A

Wernicke-Korsakoffsyndrome (WKS) is a neurological disorder. Wernicke’sencephalopathy andKorsakoff’spsychosis are the acute and chronic phases, respectively, of the same disease. WKS is caused by a deficiency in the B vitamin thiamine and is most frequently encountered in alcoholics.

Acute thiamine deficiency
Precipitated by providing calories in the absence of sufficient reserves of thiamine
i.e. by refeeding

30
Q

Give the symptoms of Wernicke’s

A

Opthalmoplegia, unsteady gait, nystagmus, confusion

This is reversible – but only if you act very quickly to give IV thiamine

31
Q

Give the symptoms of Korsakoff’s psychosis

A

Sudden onset, dramatic, irreversible memory loss, confabulation

32
Q

How do you avoid/treat Wernicke’s?

A

Be aware of the risk
Replace thiamine before and during re-feeding
If low risk and able to eat use high dose oral thiamine
If high-risk or not eating then use IV Pabrinex

33
Q

Describe the ethics surrounding feeding

A

Feeding and hydration, however provided, is part of basic care & should not be withdrawn, they represent love and care for the helpless.
Withdrawing them = starving someone to death
PEG/ NG feeding
requires medical / nursing skills
has side effects
is medical treatment
And therefore could be withdrawn if thought not to be providing benefit

Where artificial nutrition and hydration is necessary to keep the patient alive, the duty of care will normally require the doctors to supply it…. but…
If feeding requires medical intervention
AND
Is not thought to be providing benefit
Then there may be circumstances in which it should not be done

34
Q

How could a PEG be of benefit?

A

Improved life expectancy

Improved quality of life
medication can be given vs. symptoms/pain
Increase / maintenance of weight
improvement of healing e.g. pressure ulcers

Improved daily activities
increased capacity for rehabilitation

The alimentary system (21 decks)

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