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104 theme 1 - the alimentary system > What all doctors should know abut nutrition support > Flashcards

What all doctors should know abut nutrition support Flashcards

1
Q

In what ways 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

What are the routes of oral nutritional support?

A
  • FOOD FIRST
  • Safest
  • Cheapest
  • Most acceptable
  • UNLESS IT IS CONTRA-INDICATED:
  • Unsafe swallow
  • Damaged/non-functioning gut
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3
Q

What are the 2 reasons oral could fail and need to move on to enteral?

A
  • Unsafe swallow
  • Unable to eat enough despite oral nutrition supplements
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4
Q

How would you feed if oral is unsuccessful?

A

ENTERAL = using the gut

  • Unless contraindicated – damaged / leaking / short / atonic / obstructed gut
  • PARENTERAL = bypassing the gut
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5
Q

What is enteral nutrition and when would it be used?

A
  • Nutritionally complete liquid feeds through various tubes which access the gut
  • Use IF GUT FUNCTIONING

–Unable to swallow

Includes unconscious

–Insufficient oral intake despite supplements

–Unable to tolerate supplements

–Patient choice

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6
Q

What is parenteral nutrition and when would it be used?

A

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

•

•Use IF GUT NOT FUNCTIONING

–Aperistaltic

–Obstructed

–Too short (most always when less than 100cm of small bowel remaining)

–Too damaged

–High fistula

Inaccessible

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7
Q

Is this tube in the right place?

A
  • chest x-ray view - YES
  • NG tube should remain in the midline - NO
  • NG tube should bisect the carina - NO
  • tip of the NG tube should be clearly visible and below the diaphragm - NO
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8
Q

Complete the diagram

A
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9
Q

How are enteral feeds named?

A

•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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10
Q

What are the advantages of Naso-gastric 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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11
Q

Who is Naso-gastric 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 (up to 8 weeks)

e.g. whilst unconscious on ITU, post-op, post-stroke, acute illness

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12
Q

What are the risks of Naso-gastric feeding?

A

–Tube misplaced / displaced / blocked

– Reflux / aspiration

– Not tolerated

•Tube itself or volume of feed infused

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13
Q

How is correct placement on an NG tube confirmed?

A
  • The chest x-ray view should be adequate – upper oesophagus down to below the diaphragm
  • The NG tube should remain in the midline down to the level of the diaphragm
  • The NG tube should bisect the carina (T4)
  • The tip of the NG tube should be clearly visible and below the 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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14
Q

What is a NG care bundle?

A
  • Safety checklist
  • Aimed at avoiding feeding through a misplaced tube
  • Lots of documentation required to assure adherence to care plan
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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

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17
Q

What is PEG and RIG?

A

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

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18
Q

What are the advantages of PEG and RIG?

A

Advantages

–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
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19
Q

Who is PEG and RIG 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 PEG or 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 Surgical jejunostomy / PEJ / RIJ?

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 for 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 does total parenteral nutrition include?

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

How is a central access line put in?

A

Use superior vena cava -

  1. Subclavian
  2. Superior vena cava
25
Q

What are the 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
  • £££££
26
Q

How is TPN monitored?

A

•4 hourly:

–Observations including temperature

–Blood glucose

•Daily:

–U&E, Mg, Ca, phosphate, LFT, FBC

–Line inspection

–Weight

•Monthly:

–Micronutrients

Triglycerides

27
Q

What is the definition of 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.

28
Q

What is the pathogenesis of refeeding syndrome?

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

29
Q

How to avoid/treat refeeding syndrome?

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

30
Q

What is the definition of wernicke – korsakoff’s syndrome - wks?

A

•Wernicke-Korsakoff syndrome (WKS) is a neurological disorder. Wernicke’s encephalopathy and Korsakoff’s psychosis 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.

31
Q

How does wernicke-korsakoffs syndrome occur?

A
  • Acute thiamine deficiency
  • Precipitated by providing calories in the absence of sufficient reserves of thiamine

–i.e. by refeeding

32
Q

What are the symptoms of wernicke’s?

A
  • Wernicke’s: opthalmoplegia, unsteady gait, nystagmus, confusion
  • This is reversible – but only if you act very quickly to give IV thiamine
33
Q

What are the symptoms of Korsakoff’s psychosis?

A

sudden onset, dramatic, irreversible memory loss, confabulation

34
Q

How to 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

35
Q

What form of nutrition support?

  • 78 yr old female
  • Stroke affecting her right side
  • Fails a swallow assessment
  • Fit and well and eating normally until this happened yesterday
  • Already showing signs of recovery of the strength in her arm

Would you change the nutrition support?

  • One month later she has not recovered her swallow and is still very dependent
  • The team are planning to transfer her to a nursing home
A

Nasogastric tube

PEG

36
Q
  • 32 yr old male
  • Acute alcoholic pancreatitis – day 5
  • On-going nausea, vomiting
  • Only managing sips orally
  • CT shows a pseudocyst which is partially obstructing the gastric outlet

What is the most appropriate form of nutritional support?

A

Nasojejunal tube

37
Q
  • 56 yr old male
  • Found with a superior mesenteric artery infarction
  • Extensive small bowel resection
  • Only 60cm of small bowel remains
  • High output stoma (4 litres / day)

What is the most appropriate form of ns?

A

TPN

38
Q
  • 86 year old man
  • Suffering from metastatic lung cancer with a life expectancy of less than one month
  • Severe on-going weight loss
  • Has no appetite and gets nausea and vomiting every time she eats

What is the most appropriate form of ns?

A

BEST SUPPORTIVE CARE

Oral nutritional supplements / oral hydration / antiemetics

39
Q

What is the ethical significance of feeding?

A
  • “Basic care”
  • = procedures essential to keep an individual comfortable
  • Includes warmth, shelter, pain / symptom relief, hygiene measures and “the offer of oral nutrition and hydration”.
  • Appropriate basic care should always be provided unless actively resisted by the patient.
40
Q

What is the ethical dilemma in NG / PEG 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

41
Q

What is a doctors duty of care with feeding?

A

•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

A discussion of benefit vs. risk needs to be had with patient / family (NOK) involvement

42
Q

How could a PEG be of benefit in end stage dementia?

A
  • Improved life expectancy - NO
  • Improved quality of life - NO

–medication can be given vs. symptoms/pain - YES

–Increase / maintenance of weigh - YES

–improvement of healing e.g. pressure ulcers - NO

•Improved daily activities -NO

increased capacity for rehabilitation - NO

43
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

44
Q

How could a PEG be of benefit in end stage terminal illness?

A
  • Improved life expectancy - NO
  • Improved quality of life - NO

–medication can be given vs. symptoms/pain - YES

–Increase / maintenance of weight - NO

–improvement of healing e.g. pressure ulcers - NO

•Improved daily activities - NO

increased capacity for rehabilitation - NO

45
Q

How could a PEG be of benefit in a PVS (persistant vegitative state)?

A
  • Improved life expectancy - YES
  • Improved quality of life

–medication can be given vs. symptoms/pain - YES

–Increase / maintenance of weight - YES

–improvement of healing e.g. pressure ulcers - NO

•Improved daily activities

increased capacity for rehabilitation - NO

104 theme 1 - the alimentary system (17 decks)

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