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module 104 - theme 1 > what doctors should know about nutritional support > Flashcards

what doctors should know about nutritional support Flashcards

1
Q

when oral nutrition is unsuccessful how do you provide nutrition?

A
  • enteral (unless contraindicated - damaged/leaking/short/antonic/obstructed gut)
  • parenteral
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2
Q

what does enteral mean?

A

using the gut

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3
Q

what does parenteral mean?

A

bypassing the gut

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4
Q

how is enteral nutrition provided?

A

nutritionally complete liquid feeds through various tubes which access the gut

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5
Q

when do you use enteral nutrition?

A
  • if gut is functioning
  • unable to swallow (eg - unconscious)
  • insufficient oral intake despite supplements
  • unable to tolerate supplements
  • patient choice
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6
Q

how is parenteral nutrition provided?

A

nutritionally complete fluid feed which is broken down into glucose/amino acids/fats and engineers to be safely administered by IV

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7
Q

when do you use parenteral nutrition?

A
  • if gut is not functioning
  • aperistaltic
  • obstructed
  • too short (when less than 100 cm of small bowel)
  • too damaged
  • high fistula
  • inaccessible
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8
Q

what are the advantages of nano-gadtric tube feeding?

A
  • uses the gut (physiological)
  • fast and easy to pass tube
  • minimally invasive
  • generally well tolerated
  • easy to remove if not tolerated/no longer required
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9
Q

who is a nano-gastric tube suitable for?

A
  • people with a working gut
  • stomach emptying
  • safe to put tube through nose and down oesophagus
  • patient must accept/tolerate tube
  • short term feeding
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10
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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11
Q

how is the feeding tube placement confirmed?

A
  • chest x-ray view should be adequate (upper oesophagus down to below diaphragm)
  • NG tube should remain in the midline down to the level of the diaphragm
  • NG tube should biscuit the carina
  • tip of NG tube should be clearly visible and below the diaphragm
  • the tip of the NG tube should be 10cm beyond the GOJ to be confident it is within the stomach
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12
Q

what are the advantages of the naso-jejunal feeding?

A
  • vomiting/gastropareisis/duodenal obstruction
  • minimally invasive but need x-ray or endoscopy to place
  • less likely to aspirate/get misplaced
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13
Q

what are the risks of nano-jejunal feeding?

A
  • technically difficult
  • generally needs endoscopy or placement in interventional radiology
  • this can create a delay in feeding
  • risk of mis/displacement
  • may still not be tolerated
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14
Q

what is PEG and RIG?

A
  • percutaneous endoscopic gastrostomy (PEG)

- radiologically inserted gastrostomy (RIG)

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15
Q

what are the advantages to PEG and RIG?

A
  • uses the gut/physiological
  • durable (tube lasts a couple of years, unlikely to be accidentally displaced)
  • no tube in throat/on face
  • comfort
  • cosmetic
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16
Q

who is PEG and RIG suitable for?

A
  • a functioning gut
  • inability to swallow adequate food/fluid
  • dure to an irréversible or long-lasting cause
  • in whom nutrition support is thought to be appropriate
  • who can tolerate an endoscopy and minor surgical procedure
17
Q

what are the risks and shortcomings of PEG or RIG?

A
  • perforation
  • sepsis
  • 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
18
Q

what are the advantages of percutaneous jejunal access (surgical jejunostomy/PEJ/RIJ)?

A
  • as for PEG plus
  • tolerated if gastroparesis/duodenal obstruction
  • longterm option for those requiring NJ feeding
19
Q

what are the risks of 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
20
Q

what is total parenteral nutrition?

A
  • fluid
  • electrolytes
  • protein (as amino acids)
  • fat
  • carbohydrate
  • vitamins
  • minerals
21
Q

what are the problems with TPN?

A
  • line ‘access’ complications (misplaces line, extravasation of TPN, clot on the line, line infection)
  • hyperglycaemia
  • fluid/electrolyte disturbance
  • over or under-feeding
  • liver disease
  • gut not being used leading to atrophy and inflammation
  • expensive
22
Q

how do you monitor TPN?

A
  • 4 hourly observations: temperature and blood glucose
  • daily: U&E, Mg, Ca, Phosphate, LFT, FBC, line inspection, weight
  • monthly: micronutrients, triglycerides
23
Q

what is referring syndrome?

A
  • severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeeding wither orally, enterally or parenterally
24
Q

what is the pathogenesis of re-feeding syndrome?

A
  • during starvation energy is saved by switching off trans-membrane pumps
  • Na (and water) drift intra-cellularly
  • K and phosphate drift extra-cellularly (and are excreted to keep plasma levels stable) leading to total body depletion
25
Q

what are the clinical signs of re-feeding syndrome?

A

as soon as you get an energy these are switched back on immediately:

  • sudden drop in plasma K and phosphate leading to arrhythmia
  • sudden surge in plasma Na and water leading to overload
26
Q

how do you avoid/treat re-feeding?

A
  • be aware of the risk
  • check electrolytes
  • begin replacement before feeding
  • start slow and build up
  • keep monitoring electrolytes daily and replacing as necessary
27
Q

what is Wernicke-Korsakoff’s Syndrome (WKS)?

A
  • a neurological disorder

- Wernicke’s encephalopathy and Kosakoff’s psychosis are the acute and chronic phases respectively of the same disease

28
Q

what causes WKS?

A

deficiency in the B vitamin thiamine and is most frequently encountered in alcoholics

29
Q

what are the key characteristics of Wenicke/Korsakoff?

A
  • acute thiamine deficiency
  • precipitated by providing calories in the absence of sufficient reserves of thiamine
  • Wenicke’s: ophthalmoplegia, unsteady gait, nystagmus, confusion
  • this is reversible but only if you act very quickly to give IV thiamine
  • Korsakoff’s psychosis: sudden onset, dramatic, irreversible, memory loss, confabulation
30
Q

how do you avoid/treat Wenicke’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 of not eating then use IV Pabrinex

module 104 - theme 1 (17 decks)

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