1. Limited storage capacity 2. Preferred fuel source for CNS,renal medulla 3. Enteral carb = 4kcal/g, IV dextrose = 3.4kcal/g 4. Recommended 45-60% of total calories

1. major endogenous fuel source 2. 9kcal/g 3. contains essential fatty acids, Omega 6/3 4. Typically 10-35% of total daily calories 5. Deficiency triene:tetraene ratio > 0.2

Lecture 5 - Enteral Nutrition Flashcards by Patryk Lasiuk

Goals of nutrition support

Provide consistent nutrition support
Prevent deficiencies
Provide adequate nutrition to meet metabolic needs
Avoid complications
improve patient outcomes

How well did you know this?

Not at all

Perfectly

Assessment of Nutritional Status

Growth Curves
Intake/output
Weight
Anthropometric measurements
Visceral proteins
24hr urine studies
Immune function tests

How well did you know this?

Not at all

Perfectly

Methods to Calc fluid requirements

Method 1:
Young healthy adult = 40mL/kg/day
other adult = 35mL/Kg/day
Elderly = 25mL/kg/day

Method 2:
> 50yrs old, 1500ml + 20ml/kg for each kg > 20
< 50yrs old, 1500ml + 15ml/kg for each kg > 20

How well did you know this?

Not at all

Perfectly

Harris Benedict Formula

BMR (men):
66 + 13.7wt(kg) + 5Ht(cm) - 6.8(age)

BMR(women):
655 + 9.6Wt(kg)+1.8(Ht) -4.7(age)

How well did you know this?

Not at all

Perfectly

Actual Energy Expenditure

BMR X activity factor X injury (stress) factor

How well did you know this?

Not at all

Perfectly

Activity Factors

Bed Rest = 1
Ambulatory = 1.3
Fever = 1.13

How well did you know this?

Not at all

Perfectly

Risk Factors

Starvation = 0.7
Surgery = 1.2
Trauma (severe) = 1.35
Head Injury = 1.5
Sepsis = 1.6
Burn < 40% TBSA = 1.5
Burn > 40% TBSA = 2.1

How well did you know this?

Not at all

Perfectly

If patient is obese then use….

adjusted bodyweight

How well did you know this?

Not at all

Perfectly

If over feeding pt (> 40kcal/kg/day) can lead to..

Fatty liver
Hyperglycemia
Prolonged mechanical ventialtion 2 excess CO2 production

How well did you know this?

Not at all

Perfectly

Indirect Calorimetry

Gold standard
Measure O2 consumption + CO2 produced
Done for severe hours
Also determines respiratory quotient

How well did you know this?

Not at all

Perfectly

RQ levels

0.85 = goal
> 09 = suggest overfeeding
0.7 = predominate fat utilization

How well did you know this?

Not at all

Perfectly

Carb ino

Limited storage capacity
Preferred fuel source for CNS,renal medulla
Enteral carb = 4kcal/g, IV dextrose = 3.4kcal/g
Recommended 45-60% of total calories

How well did you know this?

Not at all

Perfectly

Fat info

major endogenous fuel source
9kcal/g
contains essential fatty acids, Omega 6/3
Typically 10-35% of total daily calories
Deficiency triene:tetraene ratio > 0.2

How well did you know this?

Not at all

Perfectly

Protein daily intake

Health adult = 0.8g/kg/day

Severe burn pt = 2g/kg/day

How well did you know this?

Not at all

Perfectly

Typical nutritional requirements for healthy adult

Calories: 25-30kcal/kg/day
Protein: 0.8-1g/kg/day
Fluids: 30ml/kg/day

How well did you know this?

Not at all

Perfectly

Surgical patients at risk for…

increased risk of malnutrition

inadequate intake
surgical stress
increased metabolic rate
wound healing = anabolic state

How well did you know this?

Not at all

Perfectly

Strongest predictor of surgical outcomes is….

Inverse relationship between pre op albumin lvls and morbidity and mortality

Takes awhile to increase due to 1/2life….~20days
Acute phase response, check with CRP

How well did you know this?

Not at all

Perfectly

Prealbumin

shorter 1/2life than albumin, so can asses acute changes in nutritional status

tests more expensive

Check with CRP

How well did you know this?

Not at all

Perfectly

Other ways to assess nutritional success?

Nitrogen balance

Protein intake gm/6.25 - (UUN + 4) = balance in g

Positive value = Intake of N2 > losses = good
Negative value = Intake of N2 < losses = bad

Traditional Post OP nutritional Care

when to restart “house” diet depends on condition of GI tract
oral feeding delay 24-48hrs post op
Start clear liquids when bowel function returns…shouldn’t be on this for more than a few days

Enteral Nutrition

used when oral intake is inadequate or CI
Utilizes delivery of nutrition via a tube into GI tract
** req functional GI tract **

Indications for Enteral nutriton

prev malnourished patient unable to eat for > 5-7days
Adequately nourished pt unable to eat > 7-9days
adaptive phase of short bowel syndrome

CI to Enteral nutrition

Severe acute pancreatitis
High output enteric fistula distal to feeding tube
Severe GI dysfunction
Inability to obtain access
Intractable V/D
expected need < 5 days malnourished or <7-9days normally nourished

Benefits of Enteral nutrition

Prevents guy atrophy
preserves guy barrier function
decreases bacterial translocation
promotes peristalsis
Less expensive than parenteral nutrition

Typical EN patients....

Functional GI tract | Inadequate oral intake

Conditions where EN used

1. impaired nutrient digestion 2. inability to consume adequare oral nutrition 3. malabsorption 4. impaired metabolism 5. severe wasting/growth retardation

NG Tube

1. Short Term 2. Intact gag reflex 3. Normal gastric function 4. low aspiration risk 5. easy tube placement, no surgery required 6. allows for bolus/intermittent feedings

G tubes

1. surgically placed directly into stomach 2. long term, > 30days 2. allows for bolus/intermittent or continuous feedings

PEGs

1. placed through endoscope 2. Different kinds, G/J tubes 3. Allow for gastric decompression and simultaneous JT feedings 4. tube in intestine not stomach

Standard formula

``` Polymeric Normal/minimally impaired digestion Required absorption Intact protein meal replacement May contain fiber ```

Hydrolyzed formula

for GI compromise Improved digestion Protein typically small peptides

Elemental

``` Limited GI function minimal residue Protein is free amino acid minimal fat or high % MCT oil $$$, taste bad tho ```

Disease specific formulas

signed for specie organ dysfunction or metabolic abnormality may or may not be nutritionally complete

Methods of EN delivery

Bolus gravity pump = if small bowels

G tube feeding

Continuous 1st Start 30ml/hr, advance in 20ml q8hrs to goal volume Bolus start 120ml bolus, inc by 60ml q bolus to goal, freq = q3-8hrs check for residuals

Small bowel J tube feeding

continuous feeding only start 20ml/hr, inc 20ml hrs to goal dont check for residuals

Gastric residuals

Check q 6hrs If > 150ml, replace residual, old feeds X 4hrs and recheck If < 150ml, restart if still more than 150, continue to hold

Monitoring G tube feedings

Gastric residuals Blood sugar Complete chem panel q weekly Check albumin, prealbumin q week

Aspiration precautions

1. Keep head of bed > 30deg all time | 2. ****don't use blue dye to test for aspiration***

Complications of EN

1. access 2. administration 3. GI 4. Metabolic 5. Psychologic

Mechanical complications of Tubes

1. inadvertent tube removal 2. tube kinking 3. clogging 4. inadvertent intubation 5. leakage of gastric contents into the abdomen

Infectious complications of tubes

Aspiration pneumonia, Risk = altered mental status, GI dysmotility, prevent b keeping head of bed elevated Percutaneous tube site infections Upper respiratory infections

Diarrhea info

Major cause of EN interruption Maybe due to meds C.diff prone Management - switch to peptide-based or semi-elemental formula...add fiber

Medication admin with tube

1. Liquid form when available 2. Dilute thick meds 3. Watch Sorbital content** 4. Crush tab, mix with water to form slurry 5. Flush tube w/ water before and after giving dose, 1 at time 6. *****Dont Mix meds with feeding*****

Determining EN prescription

1. Estimate calorie, protein,fluid needs 2. select most appropriate EN formula 3. Determine route 4. determine method (continuous vs bolus) 5. Determine goal rate/volume