EN and PEN Flashcards
(167 cards)
1
Q
List types of short-term EN
A
NG, nasoenteric (ND, NG), OG, OD, OJ
2
Q
List types of long-term EN
A
PEG, gastostomy, jejunostomy
3
Q
What is a PEG tube?
A
PEG=percutaneous endoscopic gastrostomy tube
These are direct access from outside source to GI tract. Can handle well as long as keep site on skin clean.
More invasive. Allow for larger bolus feeds for food and medication compared to short-term.
4
Q
What are the adv/disadv of a jejunostomy?
A
Jejunostomy adv: decreases risk of aspiration. don’t have to worry about reflux from stomach into esophagus. More difficult to place.
Also need infusion pump for feeds.
5
Q
List types of peripheral PN
A
peripheral vein
midline catheter access
6
Q
List types of central parenteral nutrition
A
central venous catheter (subclavian=SC, internal jugular=IJ, femoral)
7
Q
List yptes of central PEN
A
central venous catheter (SC, IJ, femoral)
peripherally inserted center cathter=PICC.
8
Q
More concentrated PN must be administered through
A
central veins
9
Q
PICC is a ___ line
A
central
10
Q
What is combination feeding?
A
administration of both EN and PN
bridge therapy for pts who are unable to meet caloric/protein req with EN
preserves enterohepatic circ and barrier function of the GI tract
11
Q
risk factors for malnutrition
A
- unintentional weight change (>10% w/in 6 mo or >5% w/in 1 mo)
- body weight 20% under IBW
- NPO >7-10 d
- incr metabolic needs
- inadequate nutrient intake (alcoholic/substance abuse, chronic disease states, deficiencies)
12
Q
describe acute malnutrition
A
status of protein-depleted pt w adequate fat reserve
13
Q
desribe chronic malnutrition
A
depletion of pro and fat stores, w class emaciated-appearence
14
Q
SGA for normal noursihment
A
no wt loss (<0.5-1 kg)
no abnormal dietary ntake
no hx of <2d of anorexia, N/V, diarrhea
15
Q
SGA for moderate malnourishment
A
wt loss of 5-10% of usual wt in 6 mo
abnormal dietary intake for 1 mo
hx of anorexia, N/V or diarrhea for short time
16
Q
SGA for severe malnourishment
A
wt loss of >10% in <6 mo
inadequate intake for >1 mo
hx of anorexia, n/V, or diarrhea for >1 mo
**=====> visual somatic protein wasting; BMI<18.5 `
17
Q
Define Kwashiokor
A
protein malnutrition:
caused by dietary deficiency of protein for several wks/mos
18
Q
Features of Kwashiokor
A
hypoalbuminemia anemia edema muscle atrophy delayed wound healing imp'd immunocompetence
19
Q
Define Marasmus
A
protein-calorie malnutrition
devos over mo-yrs
20
Q
Features of Marasmus
A
wt loss reduced BMR depletion of SQ fat decr tissue turgor bradycardia hypothermia
21
Q
What is an appropriate visceral protein to monitor for acute nutritional status?
A
pre-albumin
t1/2=2-3 d
22
Q
What visceral proteins are used to assess nutritional status?
A
albumin
pre-albumin
transferring
retinol-binding
23
Q
Measuring ___ can be used to individual daily protein reqs
A
24 hr urine collection (UUN)
24
Q
Define nitrogen balance
A
measurement of urinary excretion of nitrogen as urea
=N(in) minus N(out)
25
During times of stress urinary nitrogen excreteion incr or decr?
increases as stress causes proteins to be broken down.
26
List non-urinary sources of nitrogen loss.
```
sweat
feces
respiration
GI fistula
wound drainage
burns
```
27
How to calculate daily nitrogen intake.
24 hr protein intake (g)/6.25
28
How to calculate nitrogen output
24 hour UUN (g) + 4
| UUN=urinary urea nitrogen
4 is a correction factor that accounts for non-urinary nitrogen losses
29
What is the goal nitrogen balance?
zero for maintenance
| ******* +4 g for repletion
30
How many kcal/g of protein?
4 kcal/g
31
How many kcal/g of carbs?
3.4 kcal/g
32
How many kcal/g of IV lipids?
10 kcal/g
33
What to monitor for refeeding syndrome?
Mg, Phos, K levels
34
What is the metabolic response to stress such as illness or injury?
hypermetabolism and hypercatabolism
increased sympathetic NS stimulation
35
What occurs during incr'd SNS stimulation as a metabolic response to stress?
incr counterregulatory hormones (catecholamines, cortisol, glucagon, GH)
incr cytokines (TNF-alpha, interleukins 1&6)
incr immunomodulators--thromboxanes and prostaglandins
36
What is the end results of metabolic responses to stress?
accelerated proteolysis, glcogenolysis, lipolysis, gluconeogenesis, & insulin resistance
37
What does proteolysis during acute stress result in?
negative nitrogen balance and weight loss
38
What does a reduced tolerance to carbs during acute stress result in?
hyperglycemia
39
What does reduced fat utilization during acute stress result in?
hypertriglyceridemia
40
What is BEE?
Basal energy expenditure = BMR
metabolic activity req'd to maintain life
41
What is RRE?
resting energy expenditure or resting metabolic rate
of calories eq'd during 24 hrs in a non-active states
~10% higher than BEE (accounts for thermal effect of food, awake state)
42
What is TEE?
total energy expenditure
calories req'd to maintain current body wt
TEE=BEE x activity or stress factor
43
activity factor for bed rest/sedentary
1.2
44
activity factor for ambulatory
1.3
45
activity factor for anabolic
1.5
46
stress factor for non-malnourished adult s/p minor surgery
1.2
47
stress factor for adult w/ongoing sepsis, severe thermal injury, or hx severe malnutrition
1.4-1.5
48
If actual BW <130% IBW use
actual BW
49
if actual body >130% IBW use
nutritional BW
50
obese pts (>150% IBW) use
IBW
51
**goal daily calories fi non-stressed, non-depleted
20-25 kcal/kg/d
52
**goal calories if trauma/stress/surgery/critically ill
25-30 kcal/kg/d
53
**goal calories if major burn
35-40 kcal/kg/day
54
**goal calories for obesity
22-5 kcal/kg/day
| use IBW
55
**goal protein for maintenance
0.8-1 g/kg/d
56
**goal protein for mild-moderate condition (repletion/med floor)
1-1.5 g/kg/d
57
**goal protein for mod-severe condition (trauma, surgery, ICU)
1.5-2 g/kg/d
58
**goal protein for burn
2-2.5 g/kg/d
59
**goal protein for obesity (>150% IBW)
2 g/kg/d
| use IBW
60
standard distribution of non-protein calories
70% dextrose
| 30% fat
61
concurrent disease states for adjusting distribution of non-protein calories
DM, renal, hepatic dx
blood sguar
TG
concurrent infx of sepsis (consider omitting fat)
62
How to measure energy expenditure
indirection calorimetry
R!=VCO2/VO2
Goal R1=0.85-0.95
If RQ>1 = overfeeding and lipogenesis
63
RQ values for oxidized substrates
0.7 for fat
0.8 for proteins
1 for carbs
64
Phsyiologic adv of EN over PN
maintain gut integrity, prevent villi atrophy
65
immunologic adv of EN over PN
fewer infectious complication than PN, prevent bacterial translocation
66
safety adv of EN over PN
avoid catheter sepsis, embolus, arterial laceration, pneumothorax
67
cost adv of EN over PN
less expensive than PN, less equipment/personnel
less waste
68
indications for NE
inability to consume o abs adequate nutrients due to inability to consume orally (burn/trauma) or where oral consumption is contraindicated
69
contraindications for oral consumption
```
CVA; dysphagia
dementia
head and neck surgery
esophageal obstruction
trauma/burn
```
70
contraindications for EN
```
expected need <5-10d
severe acute pancreatitis
high-output proximal fistuals
inability to gain access
intractable vomiting and diarrhea
GI ischemia
ileus
```
71
describe continuous EN admin
pump, lower risk for abdominal distention d/t smaller volume, better tolerated
72
describe intermittent EN admin
several feeds, gravity admin; >200 ml over 20-30 min
73
describe bolus EN admin
>200 mL over 5-10 min in gastostomy; higher aspiration risk
but adv is fewer feedings
74
describe cyclic EN admin
over 8-20 h/d, depending on volume tolerance
also uses a pump, spread out over more time
75
What is the usual calorie density of EN formulation?
1-2 kcal/mL
76
What is the usual calorie density of EN formulations for fluid restriction?
2 kcal/mL
77
What is the carb content of EN formulations?
glucose polymers for TFs, simple glucose for PO supplements
78
what is the protein content for EN formulations?
intact or partially digested peptides (malabs or diarrhea)
79
what is the fat content of EN formulations?
long, medium-chained FAs
80
What are non-macronutrients included in EN formulations?
```
fiber
water
electrolytes
MVI
trace elements
```
81
What are immune-modulating ingredients in EN formulation?
omega-3 FAs
gluatmine
arginine
82
What are appropriate EN formulations for pts w kidney disease?
calorically dense
var. protein
low elytes
83
What are appropriate EN formulation for pts w liver disease
higher BCAA/AAA ratio, high calories
84
What are appropriate EN formulations for pts w lung disease?
high fat
| low carb
85
What are appropriate EN formulation mods for pts w DM?
high fat
| low carb
86
What are appropriate EN formulation mods for pts that need immune modulation?
glutamine
arginine
omega-3 FAs
87
EN supplements for protein
1 gel tube Prostat = 15 g protein
| 1 packet Beneprotein = 6 g protein
88
En supplements for carbs
polycose, cuocal, benecalorie
89
EN supplements for fiber
benefiber
90
Mechanical EN complications
feeding tube misplacement, clogging, aspiration
airway/GI injury leading to resp compromise or abdominal abscess/infx
91
GI complications of EN
gastroparesis
GERD
diarrhea
constipation
92
metabolic complications of EN
hyperglycemia
elyte, vit, mineral def
refeeding syndrome
dehydration
93
Initial monitoring parameters for EN
I/O
wt
feeding tube position and site
gastric residual volume
94
daily monitoring parameters for EN
I/O
wt
number and consistency of stools
abdominal distention
95
prn monitoring parameters for EN
chemsticks
feeding tube position and site
gstric residual volume
96
Oral med admin w/EN
common
many meds can be crushed, admin'd in feding tube, then flushed w sterile water
do NOT crush meds w special delivery systems
avoid mixing liquid meds w EN formulation d/t phys incompatabilities
97
How to unclog feeding tubes
pancreatic enzyme tablet
NaHCO3 tab
10 mL warm water
98
How to prevent drug-nutrient interactions w continuous feed EN
interrupt to give meds
99
how to prevent drug-nutrient interactions w bolus feed EN
space meds btw TFs
100
Example of drug-nutrient interactions in EN
```
phenytoin
fluoroquinolones
tetracyclines
warfarin
PPIs (omeprazole, lansoprazole)
```
101
Describe TNA PN formulation
Total Nutrient Admixture or 3-in-1
carbs, fat, and AA in same IV admixture
milky appearance
102
Describe 2-in-1 PN formulation
carbs, AA in same admixture
several commercially prepared pre-mixed formulations
fat infused separately
103
Central PN
delivered by a large diameter vein
Central line (SC, IJ, femoral) or PICC
104
PPN
periphal parenteral nutrition
by peripheral vein of hand or forearm
105
limitations of PPN
dextrose 12.5%
Ca and Phos content
Osmolarity (max 900-1100 mOsm/L)
106
PPN not recc'd for
severe stress
malnutrition
considerable caloric/elyte reqs
PN >5 d
107
indications for PPN
```
nonfunctioning/inaccessible GI tract:
bowel ischemia
intractable vomiting/diarrhea
hyperemesis gravidum
GI bowel obstruction/ileus
severe IBD
short bowel syndrome
```
prolonged NPO course >7d
108
contraindications for PN
```
functioning GI tract
treatment <7d in pts w/o severe malnutrition
inability to obtain venous access
prognosis does not warrant PN
when risks exceed benefits
```
109
max carb utilization rate
4-5 mg/kg/min
110
proprofol 10% provides
1.1 kcal/mL
111
PN for egg allergy pts?
cannot use fat emulsion bc egg yolk phospholipid is used
112
max intake of fat emulsion in PN
2.5 g/kg/d lipid
| not to exceed 60^ of daily caloric intake
113
EFAD
essential fatty acid deficiency
must include lineoleic and linolenic acid
can result from several day sof therapy w/o fat supplementation
114
Na in PN
1-2 mEq/kg/d
added as Cl, acetate, or phosphate; largely dep on fluid balance of pt
115
K in PN
1-2 mEq/kg/d
added as Cl, acetate, or phosphate
116
Phosphorus in PN
20-40 mM/d
| 1 mM phosphate supplies 1.33 mEq Na or 1.47 mEq K *****
117
Ca in PN
10-15 mEq/d
added as gluconate; watch Ca-Phos to avoid precip
118
Mg in PN
8-20 mEq/d
| high demands in catabolic/malnourished pts
119
vitamins in PN
RDA
| include ADEK, ascorbic acid, B complex
120
trace elements in PN
RDA
| include Zn, Cu, Mn, Chromium, selenium
121
increased Cl ratio (vs acetate) for micronutrient PN rec'd in:
metabolic alkalosis d/t K def
loss of gastric contents from vomiting
gastric decompression
122
When is an increased acetate ratio (vs Cl) rec'd for micronutrients in PN?
```
RF
metabolic acidosis due to excessive bicarb loss in RTA
massive diarrhea
small bowel
pancreatic fistulas
```
123
Acetate is converted in the body to ___ in a ___ ratio
bicarbonate
| 1:1
124
PN solutions are intially formulated to provide ___ of cation salts as __ and __ as ___
2/3 as chloride
| 1/3 as acetate
125
Possible additives in PN
H2-antagonists
Regular Insulin
Heparis is mostly EXCLUDED
Albumin should NOT be added to PN
126
Regular insulin in PN
hyperglycemia cases:
0.1 U/2.4 kcal dextrose
high insulin req should be maintains via separate drip
[don't include <10 U b/c binds to plastic; really only for long term insulin needs]
127
What are examples of mechanical complications in PN?
infusion pump failure
catheter-related: pneumothorax, migration to wrong vein, improper position w/in cardiac chambers, arterial puncture, bleeding
128
What are examples of infectious complications in PN?
central venous catheter (CVC) infx
| infx 2/2 soln contamination (rare)
129
What are examples of metabolic complications of PN?
```
liver disease
hypertriglyceridemia
hyperglycemia
refeeding syndrome
essential FA def
metabolic bone disease
```
130
When to monitor Chem 6 for PN?
initially, daily (unstable), 1-2 x /wk (stable)
same for BUN, SCr, and glucose!
131
When to monitor albumin for PN?
initially
| 1-2 x/wk 9stable)
132
when to monitor prealbumin in PN?
prn
133
Monitoring PT/INR prn n PN is useful bc
bleeding risk
assess certain micronutrients: vit K, Calcium
134
Describe Refeeding Syndrome
fluid and elyte abnorm ass'd w metabolic complications that devo during nutrition repletion in malnourished pts
for example, new glc load --> insulin --> ATP --> need phos --> hypohpos (symp)
insulin --> decr K --> hypokal --> hypomag
135
Important clinical manifestations of hypophosphatemia
Sz
coma
death
136
Important clinical manifestations of hypokalemia
cardiac arrhythmia
atrial tachycardia
sudden death
137
Important clinical manifestations of hypomagnesemia
Sz
coma
death
138
Important clinical manifestations of vitamin/thiamine deficiency
lactic acidosis
| death
139
Important clinical manifestations of sodium retention
fluid overload
pulmonary edema
cardiac decompensation
140
How to prevent refeeding syndrome
identify pt at risk
correct elyte abnormal before nutrition
start low and go slow: ~25% of goal on day 1, incr over 3-5 d
141
___ affects the stability of IV lipids
pH: coagulates in acidic environment
| this leads to problems when try to acidify bags to avoid CaPhos precip
142
TPN Destabilization to look out for
aggregation and cracking of lipid
Precipitation of CaPhos
143
how to reduce destabilization of lipds
keep AA conc at 2.5% or more
pH >5.0
dextorse conc >3.3%
avoid trivalent cations (iron dextran)
avoid mixing dextrose and lipid directly
add lipid last
144
how to calculate protein calories
g protein x 4 kcal/g
145
how to calculate non-protein claories
total kcal - protein kcal
146
How much space in the TPN should be used for electolytes/additives?
~150 mL
147
Always start a TPN at no more than ___ of goal.
50%
| 25% if at risk for refeeding is good start
148
Some appropriate monitoring factors for TPN
```
Accucheck
BUN
Cr
elytes (chem-6, Mg, Phos, Ca)
LFTs
alb/pre-alb
CRP
PT/INR
TG
```
149
what is the appopriate filter size for 2-in-1 TPN?
0.22 micron
150
What is the appropriate filter size for 3-in-1 TPNs?
1.2 micron
151
How to d/c TPN?
taper progressively and be sure to d/c insulin
152
Max admin of TPN in cycling TPN
200 mL/hr
153
Nutrition in short bowel syndrome
recs based on presence/absence of a colon:
w/ colon: high car-low fat (80/20)
consider vit B12 supp
154
Nutrition in DM pts
maintain glc btw 110-220 mg/dL
**140-180 mg/dL in critically ill pts
Give 30% of total kcal as fat
Gastric atony and delayed emptying is typical in type 1 DM
155
nutrition in cardiac disease pts
avoid overfeeding
| fluid restriction
156
Nutrition in renal disease
fluid restriction : 2kcal/mL EN formula
pre-dialysis: low protein
w/ renal insuff (<30 mL/min): 0.5-0.8 g/kg
w/o renal insuff: 0.5-01 g/kg
dialysis: standard protein
Intermittent HD: 1-1.3 g/kg
continuous renal replacement therapy (CRT): 1.5-2 g/kg
157
Nutrition in pulmonary failure
Calories: 20-30 kcal/kg
give 30-50% of total kcal as far;
protein: 1-2 kg/kg
limit carbs: avoid overfeeding
158
Nutrition in hepatic disease
high caloric intake: 35 kcal/kg/day
no encephalopathy, standard protein: 1-1.2 g/kg/d
encephalopathy: protein restriciton 0.6 g/kg/d
Na restriction if ascites or edema
159
Other special pops in Nutrition
```
acute pancreatitis
surgical subsets: trauma, TBI, open abdomen, burns
sepsis
SICU
chronically critically ill
obese critically ill
```
160
*Nutrition in GERD
make sure H2 antag or PPI is ordered, place in TPN if able (famotidine)
161
*Nutrition in NG suctioning
may cause hypnatremia, hypokalemia, and/or hypochloremia
162
*Nutrition in N/V
may lead to hypovolemia, Na+ imbalance, hypokalemia
163
*Nutrition in dialysis
removes 10-20% AAs
164
*Nutrition in wound healing
consider adding zinc, vitamin C
165
*Nutrition w loop diuretics
May cause hypokalemia Na+ balances
166
*Nutrition w steroids
may incr blood sugars, may need to add insulin
167
Use NBW if BMI
>30
