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[Mine] core curric - 2016 > Ch 13: Complications of EN > Flashcards

Ch 13: Complications of EN Flashcards

1
Q

Most common problem r/t N/V

A

Delayed gastric emptying

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2
Q

Potential causes of N/V

A
  • diabetic gastropathy
  • hypotension
  • sepsis
  • stress
  • anesthesia/surgery
  • infiltrative gastric neoplasms
  • autoimmune diseases
  • surgical vagotomy
  • opiate analgesics (morphine sulfate, codeine, fentanyl)
  • anticholinergics (chlordiazepoxide HCl and clidinium bromide)
  • excessive rapid infusion of formula
  • infusion of cold solution or one containing high amounts of fat and fiber
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3
Q

Interventions for N/V

A
  • Reduce or d/c all narcotics
  • Switch to low-fiber low-fat and/or isotonic formula
  • Administer feeds at room temperature
  • Temporarily reduce feeding rate by 20-25 ml/hr
  • Change infusion from bolus to continuous
  • Prokinetics (metoclopramide or erythromycin)
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4
Q

What should you do if N/V occurs as rate of administration or bolus volume increases?

A

Reduce to greatest tolerated amount and reattempt advancement after symptoms subside

If these attempts fail, obtain SB access

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5
Q

ASPEN/SCCM stance on routine checks of GRV in critically ill patients

A

ASPEN/SCCM does not recommend routine checks of GRV in critically ill patients

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6
Q

What should you monitor in patients who c/o nausea with EN?

A

stool frequency

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7
Q

Causes of distention and nausea

A
  • Obstipation or fecal impaction can lead to distention and nausea
  • Cdiff can cause distention and vomiting
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8
Q

Distention/bloating can be caused by:

A
  • GI ileus
  • obstruction
  • obstipation
  • ascites
  • diarrheal illness
  • rapid formula administration
  • infusion of very cold formula, use of fiber formula (fermentation)
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9
Q

Suspect ileus or bowel obstruction based on & how to confirm?

A
  1. physical exam and symptoms
  2. can be confirmed by a flat and upright abdominal x-ray
    * Impractical in hospitalized patients
    * “Plain” films may be nondiagnostic
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10
Q

What is an appropriate screening method if ileus or obstruction is suspected?

A

Plain radiology

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11
Q

When distention and question of feeding tube placement:

A

Contrast + follow up x-ray or fluoroscopy

  • Continue EN if intestinal appearance is normal, even with distention
  • Hold feeds if motility is poor, bowel is markedly dilated, or discomfort is too severe
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12
Q

Maldigestion & clinical manifestations

A

Impaired breakdown of nutrients into absorbable forms (e.g., lactose intolerance)

Clinical manifestations: bloating, abdominal distention, diarrhea

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13
Q

Malabsorption

A

: defective mucosal uptake and transport of nutrients (fat, CHO, protein, MN, lytes, water) from the small intestine

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14
Q

Clinical manifestations of Malabsorption

A
  • unexplained weight loss
  • steatorrhea
  • diarrhea
  • signs of macro or MN deficiency (anemia, tetany, bone pain, pathologic fractures, bleeding, dermatitis, neuropathy, glossitis)
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15
Q

Screening methods for malabsorption:

A
  • Gross/microscopic exam of stool
  • Qualitative determination of fat and protein content of a random stool collection
  • Measurement of serum carotene concentration
  • Measurement of serum citrulline levels
  • Measurement of d-xylose absorption
  • Radiologic exam of intestinal transit time and motility
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16
Q

When lab data, history, and/or radiologic exam suggest maldigestion/malabsorption, diagnosis can involve:

A
  1. I/Os (stool collections for quantitative fecal fat assessment)
  2. Endoscopic SB BX – diagnosis of celiac disease, tropical sprue, Whipple disease
  3. Tests for maldigestion/absorption of specific nutrients:
    * Lactose tolerance test
    * Schilling test to screen for abnormal absorption of B12
    * EFA profile for lipid malabsorption
    * Radioisotopic test to identify iron, calcium, AA, folic acid, pyridoxine, and Vit D malabsorption
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17
Q

Causes of maldigestion/malabsorption:

A
  • Gluten sensitive enteropathy
  • Crohn’s disease
  • Diverticular disease
  • Radiation enteritis
  • Enteric fistulas
  • HIV
  • Pancreatic insufficiency
  • SBS
  • SIBO
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18
Q

Use of semi-elemental formulas when malabsorption is suspected

A

Weak data supports use of predigested enteral formulas to prevent intolerance when malabsorption is suspected

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19
Q

What is the most commonly reported GI side effect in patients receiving EN?

A

Diarrhea

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20
Q

Definitions of diarrhea

A

Abnormal volume or consistency of stool

  • > 500 mL output x24 hours
  • > 3 stools/day for at least 2 days
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21
Q

Normal stool water is

A

250-500 mL/day

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22
Q

Etiologies of diarrhea

A
  • medications
  • primary GI disease
  • bacterial infection
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23
Q

Less likely causes of diarrhea:

A
  • characteristics of the formula (osmolality, fat content),
  • specific components of the formula (lactose)
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24
Q

Drug-induced diarrhea can be caused by:

A
  • 10-20g sorbitol can cause GI side effects like diarrhea
  • Drugs with effects on the gut – abx, PPIs, prokinetics
  • Abx-associated diarrhea (AAD) is a common medication effect (25% treated with abx)
  • Cdiff affects 10-20% of those who develop AAD
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25
Q

Most drugs and lytes (potassium) should be

A

mixed with 30-60 mL water per 10-mEq dose to avoid direct irritation of gut

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26
Q

GI diseases that can cause maldigestion or secretory diarrhea

A
  • IBD
  • SBS
  • gluten-sensitive enteropathy
  • AIDS
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27
Q

PN vs EN in GI diseases

A
  • PN may be required in some disease states
  • In other diseases, special enteral products are proposed to facilitate absorption
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28
Q

mOsm of TF vs Electrolytes

A
  • Highest osmolality of a TF is ~750 mOsm/L which is ~2.5x greater than serum
  • Electrolyte supplements have osmolalities that range from 5000-7000 mOsm/L – more likely to cause osmotic diarrhea
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29
Q

Suspicion that EN is causing osmotic diarrhea:

A

switch to isotonic formula

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30
Q

Formula dilution

A

has not been shown to improve tolerance and it contaminates the formula

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31
Q

Lactose and illness

A

Patients can develop transient lactase deficiency during illness

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32
Q

What formulas are recommended in most patients starting EN

A

Polymeric enteral formulas with intact protein

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33
Q

Management strategies of diarrhea

A
  • Medical assessment to rule out infectious or inflammatory causes of diarrhea, fecal impaction, diarrheagenic meds
  • Use antidiarrheal agent (loperamide, diphenoxylate, paregoric, octreotide) when Cdiff is ruled out or is being treated
  • Change formula type (intact protein to peptide-based formula)
  • Add soluble or insoluble fiber to medication regimen or change the TF formula to one with fiber – except in critically ill patients
  • Multiple small studies have demonstrated adding soluble fiber to EN improves diarrhea and adding fiber to EN is the recommended SOC
  • Continue EN as tolerate and initiate supplemental PN
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34
Q

Fiber-containing enteral formula vs modulars

A

Fiber-containing enteral formula preferred > modulars because the latter can clog feeding tubes

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35
Q

Fiber as an intervention with diarrhea/TF

A

Addition of fiber to EN regimen or changing TF formula should NOT be primary intervention OR the end of the evaluation/intervention for diarrhea

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36
Q

Bacterial overgrowth in the GI tract can cause

A
  • severe enteritis with diarrhea
  • abdominal cramps and pain
  • hypoalbuminemia
  • protein catabolism
  • cachexia
  • fever
  • sepsis
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37
Q

SIBO increasingly seen in which patient populations?

A

s/p Roux-en-Y GBP surgeries

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38
Q

SIBO & hydrogen breath tests

A

Hydrogen breath tests can provide false-negative results

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39
Q

Consider SIBO as differential diagnosis if

A

patient with prolonged abx therapy who presents with bloating, abdominal pain, and/or unexplained catabolism/hypoalbuminemia

40
Q

Prolonged use of what drug increases risk of SIBO?

A

broad-spectrum abx

41
Q

SIBO treatment:

A

often empiric and includes abx – nonabsorbable abx are preferred

42
Q

What patients are at greater risk for morbidity and mortality r/t formula contamination?

A
  • Neonates
  • Critically ill and immune-suppressed patients
  • Compromised gastric acid microbial barrier
43
Q

Open delivery systems & hang time

A
  • provide TF via syringe or poured into bag
  • Hang time of 4-12 hours
44
Q

Closed delivery systems –

A
  • prefilled, sterile bottles or non-air dependent containers accessed via spike or screw-top tubing
  • Hang time of 24-48 hours
45
Q

Hang time of reconstituted powdered formulas or formulas with added modulars delivered by gravity drip or pump

A

should not hang for >4 hours at room temperature

46
Q

Powdered formulas vs liquid formulas

A
  • Powdered formulas are not required to be sterile and can contain contaminants
  • Liquid formulas undergo heat sterilization
47
Q

What should you do with excess formula when preparing a feed?

A

Refrigerate excess formula that is leftover after intended volume is poured into a feeding system – max 24-48 hours

48
Q

Use of a blender to add CHO and protein modulars to a formula

A

carries a high risk for contamination during mixing and should be avoided

49
Q

Formula containers, hang time, bags

A
  • Clean lids of cans with isopropyl alcohol and let dry before pouring formula into delivery receptacle
  • Do not add additional formula to the feeding bag until the previous formula has infused
  • Feeding bag should be changed every 24 hours
50
Q

Closed delivery systems still carry a risk of contamination d/t

A

attachment tubing (touch contamination)

51
Q

Reduce the incidence of diarrhea in closed systems (ex: spike sets) by

A

replacing the tubing for closed systems every 24 hours

52
Q

Contamination can occur in a retrograde manner if

A

endogenous microorganisms (stomach, throat, lungs) reproduce within the feeding tube and then migrate into the enteral delivery system

53
Q

Checking GRV & risk of contamination

A

Checking GRV pulls potentially pathogenic microorganisms up the feeding tube and can lead to a contaminated feeding tube hub and contaminated gloves

54
Q

Y-ports of enteral delivery systems

A

are used to deliver meds and water flushes to minimize disconnection of enteral formula

55
Q

Lopez valves are 3-way stopcocks that are frequently attached to enteral feeding tubes that

A

do not contain a clamp (NG, balloon gastrostomy, balloon gastrojejunostomy, jejunostomy tubes)
* Swivel to block or allow fluid passage
* One study suggests changing Lopez valves at intervals of 3 days or less (or even at each tubing change) to avoid development of bacterial biofilm

56
Q

What type of water should be used in formulas or modulars that require reconstitution or dilution?

A

sterile water

57
Q

Small bowel dilation is rarely found in

A

uncomplicated constipation

58
Q

In patients who have constipation and require a fluid restriction:

A

use a stool softener (docusate sodium or docusate calcium, or various emollients) and a laxative or cleansing enema

59
Q

Chronic use of stimulants (senna) often results in

A

tachyphylaxis and is not indicated

60
Q

If adding fiber to the enteral regimen, administering a minimum of _ _ _ can help prevent solidification of waste in the colon and constipation

A

1 mL of fluid per kcal

61
Q

What is recommended in prevention of constipation in hemodynamically stable patients?

A

Short-chain fibers

62
Q

In older adults, impaction may be the cause of

A

confusion and agitation

63
Q

ASPEN/SCCM recommends avoiding fiber in patients who are

A

not hemodynamically stable

64
Q

What is typically seen in ischemia with EN?

A

Nonocclusive bowel necrosis (NOBN)

  • associated with a high degree of morbidity and possibly with death
65
Q

Populations that may be at greater risk for NOBN

A
  • Neonates
  • Critically ill and immune-suppressed patients
  • Compromised gastric acid microbial barrier
66
Q

All reports cite _ _ _ as precipitating factors for NOBN

A

hypotension and/or hypovolemia

67
Q

Aspiration of saliva is normal during

A

sleep

68
Q

Progression of aspiration to aspiration PNA is hard to predict and may depend on

A

quantity and acidity of formula in addition to particulates and contaminants in the formula

69
Q

Risk factors for aspiration:

A
  • low HOB
  • vomiting
  • gastric TFs (vs SB feeds)
  • low Glascow coma score (GCS)
  • GI reflux disease
70
Q

Pulmonary aspiration can occur when a patient inhales

A

oropharyngeal and gastric secretions

71
Q

After an episode of emesis and regurgitation, aspiration of TF or vomit can be presumed if patient develops

A
  • dyspnea, cyanosis, and agitation
  • and if there is evidence of new infiltrate on chest film
72
Q

FD&C Blue No. 1 dye & TFs/checking aspiration risk

A
  • Blue discoloration of body parts and fluids
  • Refractory hypotension, metabolic acidosis, and death reported
73
Q

Why is checking tracheal secretions with glucose oxidase strips not fully accurate?

A

High tracheal concentrations of glucose can be found in aspirates of nonfed patients and those with hyperglycemia, as well as in aspirates of some blood

74
Q

Accuracy of GRV measurements can be influenced by numerous factors including:

A
  • diameter and position of feeding tube tip
  • number and location of tube’s openings
  • patient’s position (altering level of stomach fluid)
  • skill of the clinician
75
Q

Raising HOB 30-45 degrees during gastric feeds has been associated with

A

decreased esophageal and pharyngeal reflux of gastric contents and a lowered incidence of aspiration PNA

76
Q

2016 ASPEN/SCCM guidelines re: GRV

A
  • Suggest not using GRV as part of routine ICU care in patients receiving EN
  • If GRV still being used, recommend avoid holding EN for GRVs <500 mL in the absence of other signs of feeding intolerance (quality of evidence: low)
77
Q

G-tubes and GRV

A

Gastrostomy tubes are positioned in the anterior abdomen and are unlikely to allow full withdrawal of stomach contents during GRV checks
* GRV >100 mL with g-tube has been suggested as trigger for evaluation of GI symptoms

78
Q

TF patients should be assessed for signs of TF intolerance – abd distention, feeling of fullness, discomfort, N/V at _ _ _ hour intervals

A

4 hour

79
Q

If tube placement is questionable,

A

a radiograph should be obtained

80
Q

Unless a patient is vomiting, GRV of _ _ _ should be re-instilled to replace _ _ _

A
  • GRV of 250 mL
  • replace fluid, lytes, and feeding formula
81
Q

Measures to reduce aspiration risk:

A
  • HOB elevation at least 30-45 degrees or positioning patient upright in chair
  • If contraindicated, reverse Trendelenburg position
  • Good oral care BID (with chlorhexidine in critically ill patients)
  • Continuous TF schedules
  • Use of minimal sedation techniques
  • Appropriate and timely oropharyngeal suctioning (ex: prior to lowering HOB, deflating cuff of trach, or extubation)
82
Q

Potassium – a total body deficit of _ _ _ is required before serum levels drop below normal

A

80 mEq

83
Q

Absorption of glucose from continuous feeds is more affected by:
A- the rate of CHO delivery
B- glycemic index

A

Absorption of glucose from continuous feeds is more affected by the rate of CHO delivery than glycemic index (which refers to rate of glucose increase after a bolus)

84
Q

Dehydraton is associated with

A
  • increased risk of falls
  • pressure ulcers
  • constipation
  • UTIs
  • respiratory infections
  • medication toxicities
85
Q

Persistent dehydration can lead to:

A

delirium, renal failure, coma, and death

86
Q

Which age group is at a greater risk for dehydration?

A

Older adults are at greater risk for dehydration – have lower water reserves d/t decreased LBM that occurs with aging

87
Q

Early signs of dehydration:

A
  • Dry mouth and eyes
  • Thirst
  • Light-headedness (especially when standing)
  • Headache
  • Fatigue
  • Loss of appetite
  • Flushed skin
  • Heat intolerance
  • Dark urine with strong odor
88
Q

Tongue dryness can be a quick, reliable, cost-effective way to

A

identify dehydration in older adults

*** As long as other etiologies of dry mouth – diuretic and anticholinergic use – are ruled out

89
Q

Signs of progressive dehydration:

A
  • Dysphagia
  • Clumsiness
  • Poor skin turgor (sternum: more than 2 seconds)
  • Sunken eyes with dim vision
  • Painful urination
  • Muscle cramps
  • Delirium
90
Q

Lab results for dehydrated patients usually show an elevation, relative to pre-dehydration levels:

A
  • Elevation of BUN, plasma osmolality, Hct
  • Serum Na levels can be elevated, low, or normal - dependent on etiology of dehydration
91
Q

In dehydration, BUN level usually rises out of proportion to the usual BUN-Cr ratio of

A

20:1

Evaluate in context of nutrition state and underlying renal function

92
Q

BUN reflects

A

protein intake, hydration status, and renal function

Example: a severely cachectic pt with renal failure, a Cr level significantly lower than 1 mg/dL, a BUN >100 mg/dL, and a BUN:Cr ratio > 100:1 may still be adequately hydrated

93
Q

Dehydration – urine-specific gravity and urine output

A

Elevated urine-specific gravity > 1.028 + low UOP usually reflects dehydration

Normal urine-specific gravity: 1.010 to 1.025

94
Q

Minimum UOP required to remove waste:

A

30 mL/hr ~ 700 mL/day

95
Q

UOP for adults:

A

0.5-2 mL/kg/hr

96
Q

Output of at least _ _ _ is useful as a guideline for adequate UOP

A

1 mL/kg/hr

97
Q

For pts with fever: increase fluid by _ _ _ % per degree Celsius above _ _ _

A

Increase fluid by 12% per degree Celsius above 37.8

[Mine] core curric - 2016 (22 decks)

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