What all medical students and doctors should know about Nutrition Support Flashcards
what is feeding
of social importance a basic requirement nurture symbolic means caring social binder psych benefits
routes of nutrition support
food first (cheapest, safest, most acceptable) unless contraindicated eg unsafe swallow, can't eat enough despite supplements, damaged/non functional gut
what happens with oral nutrition is unsuccessful
enteral - using gut
unless contraindicated - damaged/ leaking/ short/ antonic/ obstructued
then parenteral - bypassing gut
when is enteral nutrition support used
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
when is parenteral nutrition support used
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
types of enteral access
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
How can types of enteral access be distinguished
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
Nasogastric tube feeding advantages
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 suitable for Nasogastric tube feeding
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
risks of nasogastric tube feeding
Tube misplaced/ displaced/blocked Reflux/aspiration Not tolerated Tube itself or volume of feed infused
how is correct placement of NG tube ensured
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)
NG care bundle
Safety checklist
Aimed at avoiding feeding through a misplaced tube
Lots of documentation required to assure adherence to care plan
Naso-jejunal feeding advantages
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
Naso-jejunal feeding risks
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 is PEG and RIG
Percutaneous endoscopic gastrostomy (PEG) or Radiologically Inserted Gastrostomy (RIG)
Advantages of PEG and RIG
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)
who is suitable for PEG and RIG
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
risks and shortcomings of PEG and 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 is PEJ
Percutaneous Jejunal access
Surgical jejunostomy / PEJ / RIJ
advantages of PEJ
As for PEG plus tolerated if gastroparesis/duodenal obstruction
i.e. longterm option for those requiring NJ feeding
what are the risks of 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 TPN
Total Parenteral Nutrition Fluid Electrolytes Protein – as amino acids Fat Carbohydrate Vitamins Minerals via central access line to heart via SVC
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 expensive
how is TPN monitored
4 hourly: Observations including temperature Blood glucose Daily: U&E, Mg, Ca, phosphate, LFT, FBC Line inspection Weight Monthly: Micronutrients Triglycerides
what is refeeding syndrome
severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding – whether orally, enterally or parenterally.
what causes refeeding syndrome
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)
how is referring syndrome avoided or treated
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
what is WKS
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
how can WKS be avoided/treated
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
can NG/PEG feeding be withdrawn
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
how could a PEG be of benefit
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
