Enteral Nutrition

Question 1

Important consideration when assessing patients current weight

Answer 1

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

Question 2

Why is it important to review medical history of patient?

Answer 2

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

Question 3

Why is it important to review laboratory data and medications?

Answer 3

• 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.

Question 4

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

Answer 4

• 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)

Question 5

When is oral supplementation indicated?

Answer 5

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

Question 6

Indications for tube feeding

Answer 6

• 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).

Question 7

When is tube feeding considered?

Answer 7

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

Question 8

Contraindications to EN

Answer 8

• 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

Question 9

Situations for cautious use of EN

Answer 9

• 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

Question 10

Examples of significant gut dysfunction

Answer 10

• 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

Question 11

What are the modes of EN delivery?

Answer 11

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

Question 12

Describe continuous EN delivery

Answer 12

• 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

Question 13

For whome is continuous EN preferred?

Answer 13

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

Question 14

Advantages and disadvantages of continuous EN

Answer 14

Question 15

Description of cycled EN

Answer 15

Question 16

Advantages and disadvantages of cycled EN

Answer 16

Question 17

Describe intermittent/ bolus feeds

Answer 17

Question 18

Advantages/ disadvantages of bolus feeds

Answer 18

Question 19

What are transitional feeding options?

Answer 19

• cease feeds during meal times
• nocturnal feeds
• intermittent/ bolus feeds

Question 20

EN feeding routes of delivery

Answer 20

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

Question 21

Answer 21

Question 22

Answer 22

Question 23

Describe the Ligament of Trietz

Answer 23

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.

Question 24

Describe an open system versus a closed system

Answer 24

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

Question 25

Advantages versus disadvantages of closed versus open systems

Answer 25

Question 26

Types of enteral formulas

Answer 26

* polymeric: PRO is intact * semi-elemental: PRO is partially broke down (and lipids) * elemental: Amino acids (and lipids as MCT)

Question 27

Indications for use of semi-elemental or elemental

Answer 27

* short bowel * severe GI inflammation * liver disease

Question 28

Energy density of EN for adults

Answer 28

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

Question 29

Protein concentration of EN formula

Answer 29

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

Question 30

What are modular formulas?

Answer 30

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

Question 31

Adult EN formula decision tree

Answer 31

Question 32

Clinical symptoms to monitor for EN tolerance

Answer 32

* 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

Question 33

What is standard bloodwork parameters to monitor with EN?

Answer 33

* 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

Question 34

Screening and prioritizing patients for EN feeding by the RD

Answer 34

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.

Question 35

Who would you see first?

Answer 35

Question 36

Things to consider when choosing nutrition support

Answer 36

* 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)

Question 37

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

Answer 37

* **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.

Question 38

Feeding rates for a 50 kg person

Answer 38

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.

Question 39

When is ideal body weight used?

Answer 39

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

Question 40

What are the components of energy requirements?

Answer 40

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

Question 41

Ways to determine energy requirements

Answer 41

* 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

Question 42

Activity Factors

Answer 42

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

Question 43

Stress factors

Answer 43

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

Question 44

Basal fluid requirements

Answer 44

Question 45

Review case 2 and case 3

Answer 45

Week 1