What all doctors should know about nutrition Flashcards
How is feeding of social importance?
A Basic requirement Provides Nurture Is Symbolic Means “Caring” Is a Social Binder Confers psychological benefits
List the routes of nutritional support
Feeding first
Unless it is contraindicated
When may feeding be contraindicated?
Unsafe swallow
Damaged/non-functioning gut
What are the two methods used if feeding via food is unsuccessful?
Enteral
Parenteral
What is enteral feeding?
Using the gut
Nutritionally complete liquid feeds through various tubes which access the gut
What is parenteral feeding?
Bypassing the gut
Nutritionally complete liquid feed which is broken down – to glucose / amino acids / fats & engineered to be safely administered intravenously
When is parenteral feeding used?
If the gut is not functioning
Why might the gut not be functioning?
Aperistaltic Obstructed Too short Too damaged High fistula Inaccessible
Why might enteral feeding be necessary?
The gut is functioning but Unable to swallow Includes unconscious Insufficient oral intake despite supplements Unable to tolerate supplements Patient choice
List the different types of enteral access
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
What are the advantages of nasogastric tube feeding?
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
Who is nasogastric tube feeding suitable for?
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
What are the risks of nasogastric feeding?
Tube misplaced / displaced / blocked Reflux / aspiration Not tolerated Tube itself or volume of feed infused
How is correct placement of a nasogastric tube confirmed?
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
What are the advantages of naso-jejunal feeding?
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
What are the risks of naso-jejunal feeding?
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
What do PEG and RIG stand for?
Percutaneous endoscopic gastrostomy (PEG) or Radiologically Inserted Gastrostomy (RIG)
What are the advantages of a PEG?
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
Who are PEGs and RIGs suitable for?
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
What are the risks and shortcomings of a PEG or a RIG?
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
What are the advantages of a surgical jejunostomy (PEJ)?
As for PEG plus
Tolerated if gastroparesis/duodenal obstruction
i.e. longterm option for those requiring NJ feeding
What are the risks of a surgical jejunostomy (PEJ)?
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
What is contained in total parental nutrition?
Fluid Electrolytes Protein – as amino acids Fat Carbohydrate Vitamins Minerals
List some problems with TPN
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 £££££
