What all medical students and doctors should know about Nutrition Support

Question 1

what is feeding

Answer 1

of social importance 
a basic requirement
nurture 
symbolic
means caring 
social binder 
psych benefits

Question 2

routes of nutrition support

Answer 2

food first (cheapest, safest, most acceptable)
unless contraindicated eg unsafe swallow, can't eat enough despite supplements, damaged/non functional gut

Question 3

what happens with oral nutrition is unsuccessful

Answer 3

enteral - using gut
unless contraindicated - damaged/ leaking/ short/ antonic/ obstructued
then parenteral - bypassing gut

Question 4

when is enteral nutrition support used

Answer 4

nutritionally complete liquid feeds through various tubes accessing gut
use if gut functioning eg unable to swallow, insufficient intake, can’t tolerate supplements, patient choice

Question 5

when is parenteral nutrition support used

Answer 5

Nutritionally complete liquid feed which is broken down – to glucose / amino acids / fats & engineered to be safely administered intravenously
Use if gut not functioning eg Aperistaltic, Obstructed, Too short (most always when less than 100cm of small bowel remaining), Too damaged, High fistula, Inaccessible

Question 6

types of enteral access

Answer 6

into stomach to jejunum with gastric aspiration port and jejunal administration port
- PEG procedure for long term enteral feeding (or RIG)
green florae tube no guide wire for 7-10days, blue with wire for 10 days-3 months
both nasogastric
feeding post pyloric via radiologically/endoscopically placed NJ tube or surgical jejunostomy PEJ

Question 7

How can types of enteral access be distinguished

Answer 7

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

Question 8

Nasogastric tube feeding advantages

Answer 8

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

Question 9

who is suitable for Nasogastric tube feeding

Answer 9

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

Question 10

risks of nasogastric tube feeding

Answer 10

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

Question 11

how is correct placement of NG tube ensured

Answer 11

chest x ray (upper oesophagus to below diaphragm)

remain in midline down to diaphragm, bisect carina (T4), tip visible below diaphragm (10cm below GOJ to be in stomach)

Question 12

NG care bundle

Answer 12

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

Question 13

Naso-jejunal feeding advantages

Answer 13

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

Question 14

Naso-jejunal feeding risks

Answer 14

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

Question 15

what is PEG and RIG

Answer 15

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

Question 16

Advantages of PEG and RIG

Answer 16

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 and Cosmetic)

Question 17

who is suitable for PEG and RIG

Answer 17

functioning gut
Inability to swallow adequate food/fluid
Due to an irreversible or long-lasting cause where nutrition support is appropriate
can tolerate an endoscopy and minor surgical procedure

Question 18

risks and shortcomings of PEG and RIG

Answer 18

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

Question 19

what is PEJ

Answer 19

Percutaneous Jejunal access

Surgical jejunostomy / PEJ / RIJ

Question 20

advantages of PEJ

Answer 20

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

Question 21

what are the risks of PEJ

Answer 21

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

Question 22

what is TPN

Answer 22

Total Parenteral Nutrition
Fluid
Electrolytes
Protein – as amino acids
Fat
Carbohydrate
Vitamins
Minerals
via central access line to heart via SVC

Question 23

problems with TPN

Answer 23

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
expensive

Question 24

how is TPN monitored

Answer 24

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

Question 25

what is refeeding syndrome

Answer 25

severe electrolyte and fluid shifts 
associated with metabolic abnormalities 
in malnourished patients 
undergoing refeeding – 
whether orally, enterally or parenterally.

Question 26

what causes refeeding syndrome

Answer 26

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
any energy = all switched back on immediately
sudden drop in plasma K and Phos (arrhythmias)
sudden surge in plasma Na and water (overload)

Question 27

how is referring syndrome avoided or treated

Answer 27

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

Question 28

what is WKS

Answer 28

Wernicke-Korsakoff syndrome
neurological disorder. Wernicke’sencephalopathy andKorsakoff’spsychosis - acute and chronic phases of the same disease
caused by deficiency in the B vitamin thiamine and is most frequently seen in alcoholics

Question 29

how can WKS be avoided/treated

Answer 29

aware of 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

Question 30

can NG/PEG feeding be withdrawn

Answer 30

NG part of basic care and shouldn’t be withdrawn as would starve to death
PEG req medical skills, side effects, medical treatment, could be withdrawn if no benefit
when artificial nutrition and hydration necessary, duty of care means it has to be provided but can bee withdrawn in some circumstances

Question 31

how could a PEG be of benefit

Answer 31

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