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Therapeutics II > Block 2: Enteral Nutrition > Flashcards

Block 2: Enteral Nutrition Flashcards

1
Q

What are the types of nutrition support?

A
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2
Q

What is eneteral nutrition?

A

Food fomrulated to be consumed or administered enterally under the supervision of a physician that is intended for the specific dietary management of a disease or condition

Exempt from regulations on labeling and health claims

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3
Q

T/F: Critically ill patients can’t digest food?

A

Malnutrition in Critically Ill

Still Capable of Food Ingestion/Digestion

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4
Q

Why is enteral preferred over parenteral nutrition?

A
  1. Fewer infectious complications
  2. Minimize incidence of organ failure
  3. Fewer metabolic complications
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5
Q

What is EN indicated for?

A
  1. PO intake is impossible
  2. Poor appetite due to chronic condition or tx
  3. Dysphagia
  4. Major trauma, burns, critically ill
  5. Preoperative patients who are malnourished

Appropriate for patients with sufficient functioning GIT

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6
Q

CI in EN? CI in tube placement?

A

EN: Intestinal obstruction, bowel ischemia, necrotizing entercolitis
Tube: Active peritonitis, coagulopathy

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7
Q

What are the functions of the small and large intestine?

A

Small:
* Duodenum: absorption of fat, iron, folate, copper
* Jejunum: Nutrient absorption
* Ileum: Reabsorbs bile acid and Vit B12

Large: Absorbs fluid and electrolye

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8
Q

What is the difference between NG/NJ and G/J tube placement?

A

NG/NJ: manually at bedside
G/J: Surgically

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9
Q

Nasogastric or orogastric tube

Duration, Advantages, Disadvantages

A

D: Short term
Advantages: Allows for all methods of admin
Disadvantages: Increased aspiration risk

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10
Q

Nasojejunal or orojejunal

Duration, Advantages, Disadvantages

A

Duration: Short term
Advantages: Reduced aspiration risk
Disadvantages: Potential tube displacement or clogging, bolus or intermittent feeding not tolerated

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11
Q

Percutaneous endoscoic gastrostromy

Duration and Indication, Advantages, Disadvantages

A

D and I: Long term with normal gastric emptying
Advantages: Allows for all methods of admin
Disadvantages: Aspiration risk

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12
Q

Percutaneous endoscopic jejunostomy

Duration and Indication, Advantages, Disadvantages

A

D and I: Long term with impaired gastric motility or emptying
Advantages: Reduced aspiration risk
Disadvantages: Bolus or intermittenet feeding not tolerated

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13
Q

When do you start enteral nutrition?

A

Critical ill patients: Initiation between 24-72 hr decreases stress response and reduce dx severity and infection (includes malnutrition)
Healthy patients: Wait 5-7 days

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14
Q

Who should not get an early start to EN?

A

Patients with hemodynamic instabilities due to bowel necrosis from low gastric perfusion and increased O2 demand

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15
Q

What is early feeding?

A

Startign within the first 24-48 hr of admission: Goal is reaching 50-65% of caloric needs by the first week

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16
Q

What are the types of EN products?

A
  1. Standard polymeric
  2. High protein
  3. High caloric density
  4. Elemental
  5. Peptide-based
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17
Q

Standard polymeric EN

Features, Indications

A

Features:
* Isotonic
* NPC:N 125:1-150:1
* 1.2 kcal/mL

Indication:
* Majority of patients
* Functional GIT
* Not for oral use

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18
Q

High protein EN?

Features, Indications

A

Features:
* NPC: N <125:1

Indication:
* Protein requirement >1.5g/kg/d (burns, trauma, sores)
* Patient is recieving propofol

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19
Q

High caloric density EN?

Features, Indications

A

Features:
* 1.5 kcal/mL
* Lower electrolyte content per calorie
* Hypertonic

Indications:
* Patients requiring fluid/electrolyte restriction (kidney insufficiency)

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20
Q

Elemental EN

Features, Indications

A

Features:
* High proportion of free amino acids
* Low in fats

Indications:
1. Pateints who require low fat
2. Malabsorption syndromes: pancreatic insuficiency

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21
Q

Peptide-based EN?

Features, Indications

A

Features:
* Contains dipeptides, tripeptides, medium change triglycerides
* Contains MCTs

Indications:
* Protein malabsopritive syndromes (cirrhosis)

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22
Q

What is the desirable NPC:N ratio?

A

80: 1 in most stressful patients
100:1 in severe stressful patients
150:1 in an unstressed patients

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23
Q

How do you calculate NPC:N ratio?

A

NPC: N = Total non-protein calories/Total of N
total non-protein calories = total calories – protein calorie

1g N = 6.25 g protein
Carbohydrate- 4 kcal/gram
protein – 4 kcal/gram
Lipid – 9 kcal/gram

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24
Q

What is polymeric formulations?

A

Nutritionally complete, made up of mostly intact nutrients

Whole proteins, carbs from oligo or starch, lipids from veggie oil

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25
Q

What is oligomeric formulation?

A

Macronutrients that have been enzymatically hydrolyzed

Smaller, more numerous macronutrients -> higher osmolality

26
Q

What is monomeric formulation?

A

Free amino acids, glucose, oligosaccharides

27
Q

Kidney specific formulations?

A
  1. Calorie dense
  2. Low electrolyte content
28
Q

Liver specific formulations?

A
  1. Decreased aromatic amino acids (phenylalanine, tryptophan, tyrosine)
  2. high amount of branched chain amino acid (leucine, isoleucine, valine) for patients with hepatic encephalopathy
29
Q

Lung specific formulations?

A
  1. High anti-inflammatory lipid profile
  2. Low CO2 production- low carbohydrate and high fat to provide calories
30
Q

DM specific formulations?

A

Low carb

31
Q

Immune modulating formulations?

A
  1. Supplemented with glutamine, arginine, nucleotides and omega-3 fatty acids
  2. Conditionally essential aa for crit ill
32
Q

When do we switch to disease specific EN formulations?

A

If condition is not controlled by pharm or appropriate treatments

33
Q

Why are patients with ventilators given low carb formulations?

A

Carbs can increases CO2 production

34
Q

What are the steps to dose EN?

A
  1. Calculate energy needs (TEE = BEE X Activity factor X Stress factor)
  2. Calculate protein needs (Protein stress factor)
  3. Calculate fluid needs (Add additional sterile water to reach target amount)
35
Q

What are the macronutrient and total fluid needs?

A

Carbohydrate- 4 kcal/gram
protein – 4 kcal/gram
Lipid – 9 kcal/gram
Fluid: 30 mL/kg/day

36
Q

How do you calculate total energy ecpenditure (TEE)?

A

TEE = BEE (basal energy expenditure) x Activity factor x Stressor factor

37
Q

What is the activity factor of non and ambulatory patients?

A

Non: 1.2
Am: 1.3

38
Q

Where do stress factors come from?

A
  1. Minor surgery
  2. Infection
  3. Major trauma, sepsis, burns
39
Q

What are the types of tube feed admin?

A
  1. Bolus
  2. Intermittent
  3. Continuous
  4. Cyclic
40
Q

Bolus Tube Feed admin

Indication, Admin, CI

A

Indication: Gastrostomy in home or long term care
Admin: Delivered 5-10 minutes with syringe or gravity
* Initiate with full strength formula 3-8 times per day

CI:
* Delayed gastric emptying
* High aspiration risk
* Jejunal feeding

41
Q

Intermittent Tube Feed Admin

Indication, Admin

A

Indication: Gastric feeding who don’t tolerate bolus
Admin:
* Delivered over 20-60 min Q4-6H
* Admin using a reservoir bag and enteral pump or roller clamp

42
Q

Continuous Tube Feed Admin

Indication, Admin

A

Indication: Required for small-bowel feeding and preferred for gastric feedings in crit ill patients
Admin:
* Initiate full-strength formulas at 10-40 mL/hr
* Increase 10-20 mL/hr every 8-12 hrs as tolerated
* Target rate: 50 to 125 mL/hr

43
Q

Cyclic Tube Feed Admin

Indication, Admin

A

Indication: Allow PO intake and decrease on enteral feeds
Admin: Pump admin <24H, minimizes incontinences with pump and continue feeding

44
Q

What complications are we monitoring with EN?

A
  1. Metabolic: Refeeding syndrome
  2. GI: aspiration, diarrhea, gastric residual volume
  3. Infectious: aspiration pneumonia
  4. Mechanical: tube occlusion malposition

Most common risk of tube feeding is aspiration

45
Q

What are the risk factors for aspiration?

A
  1. Documented previous episodes
  2. Decreased level of consciousness
  3. Neuromuscular dx
  4. Endotracheal intubation
  5. Vomiting, regurgitation, reflux
  6. Prolonged supine position
  7. Persistently high gastric residual volumes
46
Q

What are the strategies to prevent aspiration?

A
  1. Head-of-bed elevation (30-45)
  2. Tube placement
  3. Monitoring GI motility
47
Q

What is GRV?

A

Volume of fluid in stomach after feeding

48
Q

When is it appropriate to check GRV?

A

Not a reliable marker for aspiration pneumonia unless combined with vomiting, sepsis, sedation, or pressor agents

Check Q4H for the first 48hr and Q6-8H after goal rate

49
Q

When should prokinetic agents be considered for feeding? What are the agents?

A

if ≥ 2 GRVs are > 250 mL
1. Metoclopramide
2. Erythromycin

50
Q

Metoclopramide

Brand, MOA, Dosing, BBW

A

Reglan
MOA: relaxes pyloric sphincter and duodenal bulb and enhances peristalsis of duodenum and jejunum
Dosing: 10-20 mg T-QID
BBW: Tardive dyskinesia (Psychiatric meds and Parkinsons)

51
Q

Erythromycin

MOA, Dosing

A

MOA: Stimulates smooth muscle cells by calcium-mediated event and direct motilin receptor
Dose: 200-250 mg IV Q6-12H

52
Q

What are the factors to take into account by drug delivery?

A
  1. Length of functional bowel
  2. Internal diameter and length of tube
  3. Tube composition
  4. Flushing regimen
  5. Location of distal end of the tube
  6. Size of the distal opening
  7. Compatibility of drug with feeding formula
53
Q

How should drugs be delivered by a tube?

A
  1. Do not add medication directly to an enteral feeding formula
  2. Don’t crush certain drugs
  3. Avoid puncturing liquid filled gel capsules
  4. If NPO, most of the time change to liquid form if available, however, liquid formulations are not always the answer
54
Q

What drugs should not be crushed?

A
  1. Enteric and film coated tablets
  2. Sublingual forms, modified-release dosage forms
  3. Teratogenic, carcinogenic, or cytotoxic drugs
55
Q

Why is liquid drugs not always an option in feed tubes?

A

Some must be further diluted depending on viscosity and osmolarity -> excessive fluid intake

Not optimal for those with fluid restrictions

56
Q

How do you prepare solid drugs for tube feeding?

A
  1. Prefared into a very fine powder
  2. Mixed with 15 to 30 mL of water or other appropriate solvent before administering through the tube
57
Q

How do you prepare liquid for feed tube delivery?

A
  1. Elixirs or suspensions are favored over syrups
  2. Always draw up in an oral syringe – NOT a syringe intended for injection
  3. Consider volume: Children may require a dosage adjustment
58
Q

What drugs interact with nutrient? How should we counsel patients on these meds?

A
  1. Warfarin
  2. Phenytoi
  3. Tetracyclines, Quinolones and Levothyroxine
  4. Ciprofloxacin: oral suspension

Counsel patient Flushing the tube prior and post medication administration if home EN

59
Q

How does warfarin interact with nutrient feeding?

A

enteral products binds to warfarin & amounts of vitamin K -> low INRs

Might require warfarin increase with tube feeding

60
Q

How does phenytoin interact with nutrient feeding?

A

binds to the feeding solution reducing drug level

Separate tube feeds by 2 hr

61
Q

How does Tetracyclines, Quinolones and Levothyroxine interact with nutrient feeding?

A

Chelate polyvalent cation (cal, mag, iron)

Avoid jejunal administration

62
Q

How does Ciprofloxacin (suspension) interact with nutrient feeding?

A

Oil base adheres to tube

IR tablet is crushable though

Therapeutics II (30 decks)

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