Initiating Enteral Nutrition Overview

Question 1

What is the maximum hang time for closed-system enteral formulas

Answer 1

48 hours (or based on manufacturer’s guidelines)

Question 2

A 74 year old male with history of Alzheimer’s dementia and dysphagia requires enteral nutrition as his sole source of nutrition. He presents to the hospital with a fever, hypotension, poor skin turgor an dry mucous membranes. He is 5 feet 9 inches tall and 67 kg. He is currently getting 1200mL of free water daily from the EN + 400 mL from free water flushes. His estimated calorie needs are 1800 kcals/day. How should his fluid needs be estimated?

Answer 2

30mL per kg of body weight as using mL /kcal is NOT appropriate and can lead to overhydration

Question 3

what are three methods for estimating fluid needs in enterally fed patients

Answer 3

1mL per kcal of enteral feeding (<65 years old)
Weight based (25-35kcal/kg) for adults > 65 years old
Holliday-Segar Method (1500mL for the first 20 kg and 15mL/kg for each kg remaining over 20kg)

Question 4

how is the Holliday-Segar Method calculated in adults

Answer 4

1500mL of fluid for the first 20 kg

add an additional 15ml/kg over 20 kg

Question 5

weight based fluid calculations are not recommended for

Answer 5

patients with cardiac/kidney failure issues as can lead to fluid overload

Question 6

A 56 year old female with dysphagia who is afebrile weighs 60kg, is on a standard 1kcal/mL enteral formula at 180mL/hr for 10 hours nightly. What volume of water flushes would best meet her daily estimated fluid requirements

Answer 6

1mL/kcal = 1800 mL of total water needed (same as 30mL x 60 kg of water = 1800mL)
Tube Feed Volume + 180mL/hr x 10 hours = 1800 mL, a 1mL/kcal formula contains 84% water, so 1800 x0.840 is approx 1500mL so 1800mL - 1500 mL from tube feed leaves over 300 mL of water for free water flushes

Question 7

Adult, afebrile patients who are enterally fed can have their fluid needs calculated by

Answer 7

1mL or 30-40mL/kg

Question 8

Standard enteral formulas that are 1mL/kcal contain ____% water

Answer 8

84%

Question 9

what are the benefits of starting early, appropriate enteral feedings

Answer 9

decreased bacterial translocation in the gut
preserves gut mucosal lining to decrease infection risk
decreases atrophy of the intestinal villi

Question 10

lack of feeding via the gut during critical illness may lead to ____ of the intestinal villi, predisposing a patient to _____, increased gut ___ and potentially increased ____ risk

Answer 10

atrophy
bacterial translocation of the gut
increased gut permeability
increased infection risk

Question 11

A patient is receiving EN during her 2nd trimester of pregnancy. Nutrition assessment data reflects an average maternal weight gain of 0.42 pounds a week, normal fetal growth, an albumin of 0.2 g/dL and a nitrogen balance of +2 grams a day. based on the data provided, which parameters are useful in assessing efficacy of enteral nutrition in pregnancy. Which ones are not?

Answer 11

Good indicators: maternal weight gain, fetal growth

Poor indicators: albumin, protein

Question 12

what are the most important factors in assessing adequacy and efficacy of enteral nutrition in pregnancy?

Answer 12

fetal growth & maternal weight gain

Question 13

there is a strong correlation between infant birth weight and ______ weight

Answer 13

maternal

Question 14

a positive nitrogen balance indicates adequate

Answer 14

protien provision

Question 15

A diabetic patient with early satiety, bloating, occasional vomiting & extensive weight loss. After a thorough GI workup, the patient is diagnosed with gastroparesis. What type of EN formula is most efficacious?

Answer 15

concentrated (if sensitive to volume)
standard/polymeric (esp. if given jejunum)
low in fat and fiber to avoid delayed gastric emptying

Question 16

elemental formulas are reserved for patients with

Answer 16

malabsorption and pancreatic insufficiency

Question 17

high protein enteral formulas are reserved for patients with

Answer 17

wound healing and critical care nutrition

Question 18

Lactose is a common ingredient in which type of EN formula?

Answer 18

standard infant formula as it mimics the carbohydrate content found in human milk

Question 19

Most adult medical nutrition products are _____ free because many adults are lactose intolerant, and lactase efficacy is decreased during illness

Answer 19

lactose

Question 20

Patients with chyle leaks will have trouble tolerating polymeric EN formulas becuase

Answer 20

they cannot absorb long chain fatty acids well

Question 21

Elemental EN formulas contain individual _____ and 2-3% of calories from these types of fats ______

Answer 21

amino acids

long chain fatty acids

Question 22

Patients with chyle leaks need to decrease the quantity and duration of chyle loss using ___ formulas and a ______ diet

Answer 22

elemental

low fat

Question 23

patients with Chron’s or Celiac Disease usually do well with intact macronutrients true or false

Answer 23

true

Question 24

patients with gastroparesis can usually tolerate polymeric enteral formulas especially wehn

Answer 24

they are provided in the jejunum

Question 25

In patients with pancreatitis, which parameters are important in predicting tolerance of enteral feedings?

Answer 25

APACHE II Score Duration of NPO Abdominal pain

Question 26

What is the most influential factor to determine tolerance of enteral nutrition in pancreatitis

Answer 26

disease severity as measured by APACHE II Score

Question 27

A duration of NPO > _____ days has indicated poor tolerance to EN in studies for pancreatitis

Answer 27

6 days

Question 28

Increased ______ is a clinical indication of enteral feeding intolerance in patients with pancreatitis

Answer 28

abdominal pain

Question 29

what is the rationale for starting EN

Answer 29

it may be started in patients who cannot or will not eat adequately

Question 30

Prior to starting EN, what should be considered

Answer 30

``` ethics patient & family wishes quality of life risks & benefits clinical status prognosis ```

Question 31

EN should be started when patients are expected to or have not had adequate oral intake for ______ days

Answer 31

7-14 days

Question 32

EN should not be initiated if the expected duration is less than ____ days in the malnourished patient or less than ____ days in an adequately nourished pateint

Answer 32

5-7 days (malnourished) | 7-10 days (adequately nourished)

Question 33

EN should only be started when the patient is

Answer 33

fully resuscitated or stable

Question 34

What is the preferred method of nutrition for open abdomen

Answer 34

enteral

Question 35

when should PN be started in open abdomen when

Answer 35

EN isn't tolerated for greater than 7 days

Question 36

PN is indicated in high output mid-jejunal fistula, intractable obstipation & vomiting and short bowel syndrome with < _______ cm and without a ______

Answer 36

<50 cm w/ out a colon

Question 37

what are common indications to place a gastro-jejunostomy tube?

Answer 37

diabetic gastroparesis as it bypasses the stomach to prevent nausea, vomiting during feeding

Question 38

Skin level or low profile enteral access devices have what desire features?

Answer 38

more comfortable more cosmetically pleasing can be capped when not in use

Question 39

what are cons of low profile enteral access devices

Answer 39

they require an access connector to provide meds or feedings & requires manual dexterity

Question 40

what is the gold standard for determining proper position of a feeding tube placed at the bedside?

Answer 40

radiographic confirmation

Question 41

do auscultation, pH testing, aspiration still require cxr

Answer 41

yes

Question 42

placement of a jejunostomy feeding tube would NOT be beneficial in _____ as it would increase stool output , decreased absorption

Answer 42

short bowel syndrome

Question 43

what are uses for jejunostomy

Answer 43

gastroparesis, pancreaticduodenectomy (whipple), chronic pancreatitis

Question 44

for patients with short bowel syndrome what type of enteral feeding is recommended

Answer 44

slow, continuous infusion in the stomach to maximize absorption and intestinal transit time

Question 45

compared to gastric feeding, small bowel feeding is associated with which of the following outcomes in critically ill patients

Answer 45

increased nutrient delivery, reduced GRV and reflux, shorter time to get to target goal

Question 46

what intervention may assist with the appropriate placement of a nasogastric feeding tube in an alert patient?

Answer 46

elevated the HOB have the patient in a sitting position take small sips of water

Question 47

what is most likely to facilitate transpyloric placement of a nasoenteric feeding tube

Answer 47

fluoroscopy & endoscopy or bedside electromagnetic imaging system

Question 48

what are contraindications for the placement of a PEG in a patient with liver disease

Answer 48

ascites (it may prevent the gastric and abdominal wall from being in close proximity so the trocar won't be able to pass through the stomach wall with a poor seal possibly leading to peritonitis

Question 49

what are POSSIBLE contraindications to PEG tube placement when risk vs. benefit should be evaluated

Answer 49

``` esophageal & gastric varices coagulopathy hepatic encephalopathy fulminant hepatic failure portal HTN ```

Question 50

What is an advantage of a gastrostomy feeding tube compared to an NG tube

Answer 50

gastrostomy tubes can be used in long term needs

Question 51

When EN is needed for over 4 weeks what type of feeding tube is preferred

Answer 51

gastrostomy

Question 52

do gastrostomy tubes decrease the risk of aspiration

Answer 52

no, but the due have an increased risk of gastric perforation

Question 53

Ascites is considered a relative contraindication to PEG tube as it increases the risk of

Answer 53

peritonitis

Question 54

A patient with a traumatic brain injury will require enteral nutrition for three weeks. What is the preferred method of feeding tube placement

Answer 54

naso-enteric

Question 55

what are the risks of an open feeding tube, laparoscopic feeding tube and endoscopic feeding tube placement

Answer 55

bleeding, anesthesia, bowel perforation , infection

Question 56

What is the primary advantage of a direct percutaneous endoscopic transgastric placed jejunal (PEG-J) tube vs a a PEJ

Answer 56

the PEG-J has a decreased risk of migration into the stomach

Question 57

placement of a percutaneous endoscopic _____ tube increases the risk of developing a gastric outlet obstruction

Answer 57

PEJ tube

Question 58

What characteristic of EN formulas is MOST likely to increase splanchnic blood flow in a critically ill patient?

Answer 58

high fat enteral formulas

Question 59

high fat enteral nutrition helps promote what in a critically ill patient

Answer 59

blood flow to the bowel is maxamized

Question 60

what type of enteral nutrition formula is ideal for patients at high risk for intestinal ischemia, as adequate bowel perfusion is needed for tolerance of high fiber, high osmolarity

Answer 60

isotonic, fiber free

Question 61

Hospital prepared enteral nutrition formulas should be stored at approximately what temperature

Answer 61

4 degrees C to 39 degrees F

Question 62

what is considered the danger zone for food contamination

Answer 62

5-57 decrees C

Question 63

A 60 year old female is admitted with a stroke and fails a swallowing evaluation. An NG tube is placed and the MD requests an isotonic formula. What calorie density of EN formulas is isotonic

Answer 63

1 kcal/mL which is about 300 mOsm/kg

Question 64

what is the range of osmolarity for 1kcal/mL EN formulas

Answer 64

300-350 mOsm/kg

Question 65

what is the range of osmolarity for 1.2 kcal/mL EN formulas

Answer 65

400-450 mOsm/kg

Question 66

what is the range of osmolarity for 1.5 kcal/mL EN formulas

Answer 66

500-650 mOsm/kg

Question 67

what is the range of osmolarity for 2 kcal/mL EN formulas

Answer 67

700-800 mOsm/kg

Question 68

what is the best initial enteral feeding regimen for a critically ill adult

Answer 68

full strength started at a low rate and slowly advance to goal

Question 69

why is it not encouraged to dilute enteral formulas

Answer 69

it can cause microbial growth and inadequate nutrition provision

Question 70

What is the most important intervention to decrease the risk of pulmonary aspiration during gastric tube feedings

Answer 70

elevated the HOB 30-45 degrees

Question 71

drugs that cause diarrhea are due to their

Answer 71

hypertonicity, laxative action from sorbitol or magnesium containing products

Question 72

what are drugs/medications that are known to cause diarrhea

Answer 72

medications containing sorbitol, magnesium citrate, antibiotics that cause enteritis, high TF osmolarity/bolus (sometimes)

Question 73

tube feeding is often held 2 hours before and after enteral administration of these types of meds

Answer 73

``` warfarin ciprofloxacin phenytoin carbamazepine fluoroquinolones ```

Question 74

what strategies can be employed to reduce the risk of feeding tube occlusion

Answer 74

flush with water before and after each medication

Question 75

drugs that are microencapsulated with beads or pellets are most effectively administrated through large bore feeding tubes when mixed with _______ due to the acidity to reduce the beads/pellets from sticking to the tube. The tube should also be flushed with water before and after the OJ and separately from the EN formula. Don't use warm water.

Answer 75

orange juice

Question 76

what type of enteral formulas are least likely to be contaminated with microorganisms

Answer 76

ready to hang

Question 77

what is the hang time of formula made from reconstituted powder

Answer 77

4 hours

Question 78

what is the hang time of home made blenderized enteral formulas

Answer 78

2 hours

Question 79

what is the hang time of commercially made blenderiezed enteral formulas

Answer 79

4-8 hours

Question 80

A 45 year old male is admitted with stage 4 pressure wounds, sepsis and acute respiratory failure who requires mechanical ventilation. BUN is stable, no additional excessive GI losses are noted. A polymeric high protein EN formula was started on day 1 of admit. On day 7, the primary care team requested an eval of the protein dose provided by EN. The EN formula gives 136 grams of protein (1.5g/kg/day). What is the best method to assess protein adequacy

Answer 80

nitrogen balance study

Question 81

_____ is the gold standard for assessing the adequacy of protein intake in the acute hospital setting

Answer 81

nitrogen balance

Question 82

Nitrogen balance is the difference of

Answer 82

nitrogen intake -nitrogen output

Question 83

nitrogen output as part of a nitrogen balance study is measured from

Answer 83

urine urea nitrogen from a 24 hour urine collection

Question 84

nitrogen intake as part of a nitrogen balance study is measured from

Answer 84

EN or PN intake

Question 85

what are limitations to using a nitrogen balance study

Answer 85

renal dysfunction, errors estimating output and intake

Question 86

Use of a semi-elemental or elemental formula in place of a polymeric formula should be considered with

Answer 86

intolerance to polymeric formula

Question 87

Use of immune modulating formula may be beneficial in

Answer 87

elective surgery, TBI, abdominal and torso injury from a MVA crash

Question 88

immune modulating formulas contain

Answer 88

arginine, glutamine, nucleotides, omega 3 fatty acids

Question 89

the use of immune modulating formulas is not recommended for routine use

Answer 89

use is controversial, there are inconsistent outcomes and contraindicated in septic patients 2/2 adverse effects with arginine

Question 90

what would be the most appropriate TF formula for a patient with extensive second degree burns

Answer 90

high protein

Question 91

high protein EN formulas are needed in severe burns because

Answer 91

burns cause a breakdown of lean muscle for energy and loss from wounds

Question 92

What are types of modular products for EN

Answer 92

MCT Oil Glucose Fiber Protein

Question 93

what are EN modulars used for

Answer 93

to fortify EN regimens or meals

Question 94

EN modulars should not be added directly to

Answer 94

enteral formula

Question 95

Early initiation of EN has been a suggested benefit LICU patients by reduction infectious complications, length of stay and possibly decreased mortality. Which group of patient's might be at significant risk from early EN.

Answer 95

patients with increased vasopressor support which may increase the risk of intestinal ischemia from decreased blood perfusion

Question 96

a patient with ARDS getting EN will benefit most from

Answer 96

avoidance of overfeeding

Question 97

this disease is associated with inflammation causing alveolar damage and lung capillary endothelial injury

Answer 97

ARDS

Question 98

Formulas with omega 3's are thought to be used for ARDS because

Answer 98

the omega 3 fatty acids, arginine, and glutamine may down regulate the inflammatory response induced by ARDS

Question 99

immune modulating formulas with omega 3 fatty acids are not recommended for routine use in ARDS because

Answer 99

research remains inconclusive

Question 100

The use of EN formulas enriched with branched-chain amino acids may benefit with

Answer 100

refractory encephalopathy

Question 101

Theory: liver failure is thought to increase the ratio of aromatic amino acids (AAA) to branched chain amino acids (BCAAs). BCAAs also decrease from muscle breakdown. Increased AAAs develop “fake neurotransmitters” causing encephalopathy. Only use formulas with increased BCAAs if a patient is still encephalopathic despite medicine

Answer 101

encephalopathy | unresponsive to standard medical therapy

Question 102

EN may be contraindicated in early post transplant period with hematopoietic cell transplants because of

Answer 102

potential mucosal toxicities r/t conditioning regimen that causes to GI toxicities that cause, nausea, vomiting, delayed gastric emptying, diarrhea within the first 2-3 weeks of post stem cell transplant may provide EN

Question 103

in patients with early post transplant period with hematopoietic cell transplants what form of artificial nutrition is recommended

Answer 103

there is insufficient data to establish the benefits of enteral nutrition over parenteral nutrition for hematopoietic cell transplants

Question 104

which medication would be appropriate to crush and deliver via enteral nutrition tube

Answer 104

immediate release

Question 105

____ medications should not be crushed to be put through a feeding tube as can cause medication toxicity

Answer 105

``` slow release typical abbreviations (XL, XR,SR,CD) ```

Question 106

which describes an optimal method of preparing and administering meds via enteral tube

Answer 106

flush the tube with water before and after each medication

Question 107

in patients with severe acute pancreatitis, EN has been documented to provide the following benefits over parenteral nutrition

Answer 107

EN will decrease infection rate, decrease length of stay and decrease mortality

Question 108

In a pt with fat malabsorption of an enteral products containing which of the following concentrated source of energy

Answer 108

MCT's; they are absorbed directly into the blood stream into the portal circulation by passing need for pancreatic enzymes, bile carnitine dependent transport into the mitochondria