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NUTR 476 Advanced Clinical > Enteral Nutrition > Flashcards

Enteral Nutrition Flashcards

1
Q

Important consideration when assessing patients current weight

A

dry weight verses wet weight
* consider that changes in weight that exceed 2 kg in a week is outside the ‘normal’ rate of weight gain.
* Should be worried about fluid weight gain → Does the patient have edema (acute/ chronic)?
* What is their urine output like? (mL/kg/hr 1-2 is not great and <1 is seriously low)

consult tip sheet

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2
Q

Why is it important to review medical history of patient?

A

Need to consider chronic conditions
* Review history for coinciding diseases or presenting symptoms (e.g fever, GI intolerance, respiratory distress, presence of edema)

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3
Q

Why is it important to review laboratory data and medications?

A
  • laboratory data to consider what factors may be important (e.g glucose in a patient with DM is important but may be limited value. Consider the utility of hemoglobin A1C for longer term glycemic control).
  • Medications may influence nutrition absorption (and vica versa), nutrient utilization, GI symptoms etc.
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4
Q

What to consider in terms of nutritional needs/ nutrition support regimen

A
  • NPO? (Yes/No?)
  • Route of Administration
  • Amounts ordered vs amounts received, taking into consideration anytime they will be off support
  • Establish adequacy of current nutrition support regimen by determining nutritional requirements (this will be affected by acute illness)
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5
Q

When is oral supplementation indicated?

A

Oral supplementation (energy boosting) when decreased appetite due to illness, medical treatment
* Need to assess what food it is replacing

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6
Q

Indications for tube feeding

A
  • When feeding efficiency is dramatically
  • or when sole source of nutrition (partial and total enteral nutrition support)
  • or when unsafe to consume anything orally (e.g dt swallowing issues leading to a high risk for aspiration of oral contents into lungs).
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7
Q

When is tube feeding considered?

A

Expected need for nutrition support greater than
* 5-10 days for adults
* for children 24-48 hours

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8
Q

Contraindications to EN

A
  • Expected need for nutrition support less than 5-10 days (for adults); for children 24-48 hours (unless severely malnourished)
  • When gut experiences significant dysfunction
  • Severe coagulopathy leading to ACTIVE bleeding
  • Severe portal hypertension
  • Abdominal wall infection
  • Massive Ascites
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9
Q

Situations for cautious use of EN

A
  • peritoneal dialysis (EN feed carefully)
  • Severe-acute pancreatitis; may feed carefully below Ligament of Trietz (chronic pancreatitis can feed higher up in the small bowel).
  • with partial bowel obstructions can feed distal to obstruction very carefully
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10
Q

Examples of significant gut dysfunction

A
  • High-output proximal fistulas; where IV replacement of fistula losses may be difficult, ie. the extent of diarrheal losses and problems with fluid hydration put the patient at risk for dehydration
  • Intractable diarrhea or vomiting (especially when chemotherapy places patient at high risk for upper GI bleed)
  • Complete bowel obstruction
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11
Q

What are the modes of EN delivery?

A
  • Continous (total nutrition support)
  • Cycle or altered duration (partial nutrition support)
  • Intermittent/ bolus feeds
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12
Q

Describe continuous EN delivery

A
  • Pump assisted (acute care) or gravity drip (home living)
  • 24 hour infusion prescribed as a mL/hr rate
  • often used to iniate EN in acute care settings
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13
Q

For whome is continuous EN preferred?

A
  • critically/ acutely ill
  • refeeding syndrome
  • electrolyte or glucose instability
  • demonstrated intolerance to other modes of delivery
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14
Q

Advantages and disadvantages of continuous EN

A
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15
Q

Description of cycled EN

A
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16
Q

Advantages and disadvantages of cycled EN

A
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17
Q

Describe intermittent/ bolus feeds

A
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18
Q

Advantages/ disadvantages of bolus feeds

A
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19
Q

What are transitional feeding options?

A
  • cease feeds during meal times
  • nocturnal feeds
  • intermittent/ bolus feeds
20
Q

EN feeding routes of delivery

A

Short term (<8 weeks)
* nasogastric (NG)
* nasojejunal (NJ)

Longer term feeding (endoscopic or radiological placement)
* gastrostomy (G-tubes) (PEG tube - percutaneous endoscopic gastrostomy tube)
* gastro-duodenal
* gastro-jejunal

21
Q
A
22
Q
A
23
Q

Describe the Ligament of Trietz

A

Band of smooth muscle that extends from junction of duodenum and jejunum to the diaphragm which contracts and expands, allowing the movement of intestinal contents
* Located at the junction between duodenum and the jejunum.

24
Q

Describe an open system versus a closed system

A
  • closed system: formula is already in the bag
  • Open system: transfer formula from a bottle/can/tetra into a bag
25
Q

Advantages versus disadvantages of closed versus open systems

A
26
Q

Types of enteral formulas

A
  • polymeric: PRO is intact
  • semi-elemental: PRO is partially broke down (and lipids)
  • elemental: Amino acids (and lipids as MCT)
27
Q

Indications for use of semi-elemental or elemental

A
  • short bowel
  • severe GI inflammation
  • liver disease
28
Q

Energy density of EN for adults

A

Energy density varies from 1-2 kcal/mL
* Higher energy density: typically for fluid restricted patients or patients with hypermetabolism
* higher energy formulas often have higher osmolarity and may be harder to tolerate

29
Q

Protein concentration of EN formula

A

Protein concentration can vary from 0.04 g/mL – 0.08 g/mL

30
Q

What are modular formulas?

A

Adding singular nutrient products to another formula to further increase calories, protein etc.

31
Q

Adult EN formula decision tree

A
32
Q

Clinical symptoms to monitor for EN tolerance

A
  • Abdominal distention
  • Abdominal cramping
  • Nausea , Emesis
  • Bowel movements (frequency, volume, consistency)
  • Weight maintenance or weight gain (want to stabilize at minimum and prevent protein catabolism)
  • blood work parameters
33
Q

What is standard bloodwork parameters to monitor with EN?

A
  • electrolytes
  • calcium, phosphorous, magnesium
  • glucose
  • BUN, creatinine
  • bilirubin, alkaline phosphatase, AST, ALT
  • prealbumin
  • hemoglobin
  • As required: urine urea/electrolytes/osmolarity, vitamins/minerals, serum osmolarity, CRP, triglycerides
34
Q

Screening and prioritizing patients for EN feeding by the RD

A

Consider
* nutritional status
* Duration of NPO status, safety with oral feeding (e.g dysphagia), hydrational status
* Length of time feeds to be needed; short term vs long term
* Permanent condition; this will tell you if you need permanent device or not
* Are EN feeds being used for treatment of underlying condition. Ex. feedings for patients with Crohn’s Disease (particularly small bowel).
* Stage in life cycle.

35
Q

Who would you see first?

A
36
Q

Things to consider when choosing nutrition support

A
  • tube feeding or oral supplementation? why or why not?
  • What type of feeding device would you consider?
  • Type of Enteral Feed (polymeric vs. specialized formula)?
  • Continuous vs. bolus feeds? pros and cons of both types?
  • How much Enteral feed? Ensure BMR is being met (+10% and AF)
37
Q

Feeding rates for continuous feeds for over 14 years of age (general rules)

A
  • Initiation → 0.4-0.5 ml/kg/hr (typically 10-30 mls/hr based on ASPEN guidelines)
  • progession → Over 24 hours (0.5-1 mls/kg/hr) max in one day; Most clinicians increase the rate of feeds every 8hrs by: 0.2-0.3 ml/kg/hr q 8 hrs.
38
Q

Feeding rates for a 50 kg person

A
  1. For a 50 kg patient that would mean between 20-25 mls/hr to start feeds (If a patient weights more than 60 kg, then the max rate of EN feeds to start would be 30 mls/hr)
  2. For a 50 kg patient that would mean increasing feeds between 10-15 mls/hr every 8 hours. This would mean in 24 hours about 30-50 mls/hr total in 24 hours.
39
Q

When is ideal body weight used?

A

If body weight <90% of ideal body weight or >120% of ideal body weight, use ideal body weight. Otherwise use actual body weight

40
Q

What are the components of energy requirements?

A
  • BMR (basal metabolic requirements)
  • Activity (requirements for physical activity)
  • Metabolic Stress (requirements related to metabolic stress); note many factors may influence this.
41
Q

Ways to determine energy requirements

A
  • Mifflin St Jeor:: Basal energy requirements (not total) with AF and SF
  • Kcal/kg basis (total) (eg. 25-35kcal/kg)
  • when weight gain not desired (i.e. >75yrs of age), use 25-30kcal/kg
42
Q

Activity Factors

A

Need to consider activity levels: in-patient vs. out-patient. Consider Activity Factor (variable)
* 1.0 Bed-rest
* 1.2 Out of bed; very light activity
* 1.3-1.5 Sedentary
* 1.7 Normal Activity

43
Q

Stress factors

A

Can have wide range
* for cancers often 1.1-1.3; but may be higher.

44
Q

Basal fluid requirements

A
45
Q

Review case 2 and case 3

A

Week 1

NUTR 476 Advanced Clinical (23 decks)

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