Nutrition

Question 1

Screening tool for malnutrition

Answer 1

Malnutrition Universal Screening Tool(MUST)

Question 2

Feeding preference if unable to eat sufficient calories

Answer 2

Oral nutritional supplements(ONS)

Question 3

Feeding preference if unable to take sufficient calories orally or dysfunctional swallow

Answer 3

Nasogastric tube feeding tube(NGT)

Question 4

Feeding preference if oesophagus blocked/dysfunctional

Answer 4

Gastrostomy feeding(PEG/RIG)

Question 5

Feeding preference if stomach inaccessible or outflow obstruction

Answer 5

Jejunal feeding(jejunostomy)

Question 6

Feeding preference if jejunum inaccessible or intestinal failure(IF)

Answer 6

Parenteral nutrition

Question 7

SNAP mnemonic for any patients with intestinal failure

Answer 7

Sepsis - Infection present must be corrected, otherwise feeding will be largely useless

Nutrition - Once infection is corrected, suitable nutrition should be provided

Anatomy - Define anatomy of GI tract so that surgery can be planned

Procedure - Definitive surgery once any infection eradicated, the patient nourished, and the anatomy defined

Question 8

What is ERAS

Answer 8

Enhanced recovery after surgery:

Reduction in ‘Nil by Mouth’ times

Pre-op carbohydrate loading

Minimally invasive surgery

Minimising the use of drains and nasogastric tubes

Rapid reintroduction of feeding post-operatively

Early mobilisation

Question 9

Medical management of high output stoma

Answer 9

Reduction in hypotonic fluids

Reduction in gut motility with high dose loperamide and codeine

Reduction in secretions with PPIs

Use of WHO solution to reduce sodium losses

Low fibre diet to reduce intraluminal retention of water

Question 10

What is parenteral feeding

Answer 10

IV administration of nutrients

May be supplemental to oral or tube feeding, or it may provide only source of nutrition as total parenteral nutrition(TPN)

Question 11

Peripheral lines vs central access for parenteral feeding

Answer 11

Peripheral lines may be used to deliver short-term nutritional support, but central access is necessary for feeding of more than two weeks’ duration

Question 12

Optimal method of access for central catheters

Answer 12

Ideally tunnelled subclavian vein central lines, inserted using the full aseptic technique

Parenteral nutrition solution is thrombogenic and an irritant to veins

Question 13

Method of peripheral administration in parenteral nutrition

Answer 13

Achieved through peripherally inserted central catheters(PICCs) or standard cannulae, inserted with an aseptic technique

Tolerance to peripheral lines is increased with feeds of low osmolality and neutral pH and the use of soft paediatric cannulae

Question 14

Which form of imaging can aid in getting access to central veins

Answer 14

Ultrasounded-guided venepuncture

Question 15

Feed preparations for TPN solutions

Answer 15

Iso-osmotic lipid emulsions are used to provide an energy-rich solution and reduce irritation of veins

Question 16

How should parenteral nutrition be introduced

Answer 16

Introduced at a low rate and gradually increased

TPN is usually delivered at a continuous flow rate but cyclical regimens may suit longer use

Question 17

Complications of parenteral feeding

Answer 17

Re-feeding syndrome 
Cath related complications 
Infection 
Liver and gallbladder dysfunction 
Hyperglycaemia

Question 18

What is re-feeding syndrome

Answer 18

Intracellular electrolyte stores, particularly phosphate, are depleted during starvation despite normal serum conc

Feeding stimulates cellular uptake of electrolytes and can lead to electrolyte disturbances with profound hypophosphataemia

Question 19

Clinical features of re-feeding syndrome

Answer 19

Usually develop within 4 days of re-feeding, but are often nonspecific

Later manifestations include rhabdomyolysis, cardiac failure, hypotension, arrhythmias, resp failure, seizures and coma

Question 20

Catheter-related complications of parenteral feeding

Answer 20

Immediate complications include haemorrhage, pneumothorax or haemothorax, arrhythmias or cardiac tamponade.

Long-term complications include thrombosis and pulmonary embolism, pleural or pericardial effusion, subacute bacterial endocarditis, chylothorax and venopulmonary fistula.

Question 21

Features of liver and gallbladder dysfunction in parenteral feeding

Answer 21

Majority develop mild cholestasis with elevation of transaminases and alkaline phosphatase

Gallstones and gallbladder sludging may also occur

Question 22

NICE advice regarding use of enteral feeding for post-op patients

Answer 22

Persons having surgery should not have enteral feeding within 48 hrs after surgery unless they have:

Inadequate or unsafe oral intake; and

a functional, accessible GI tract

Question 23

Features of NG tubes

Answer 23

Depend on adequate gastric emptying

Allow use of hypertonic feeds, high feeding rates and bolus feeding into the stomach reservoir

Tubes are simple to insert but are easily displaced

Question 24

Features of NJ tubes

Answer 24

Reduce incidence of GORD and are useful in delayed gastric emptying

Post-pyloric placement can be difficult but may be aided by IV prokinetics

Question 25

Indications for PEG tubes

Answer 25

Stroke Motor neurone disease Parkinson's disease Oesophageal cancer

Question 26

Relative contra-indications to PEG tubes

Answer 26

``` Reflux Previous gastric surgery Gastric ulceration Malignancy Gastric outlet obstruction ```

Question 27

How are PEG tubes inserted

Answer 27

Inserted directly through the stomach wall endoscopically or surgically under antibiotic cover

Question 28

Features of pre-digested feeds

Answer 28

Contain nitrogen as short peptides or free amino acids and aim to improve nutrient absorption in the presence of pancreatic insufficiency or inflammatory bowel disease Fibre content of feeds is variable and some are supplemented with vitamin K, which may interact with other meds

Question 29

Complications of NG tube

Answer 29

Nasopharyngeal discomfort and later nasal erosions, abscesses and sinusitis Acute complications such as pharyngeal or oesophageal perforation

Question 30

Complications of PEG or jejunostomy tubes

Answer 30

Can lead to complications related to endoscopy plus bowel perforation and abdominal wall or intraperitoneal bleeding Post-insertion complications include stoma site infections, peritonitis, septicaemia, peristomal leaks, dislodgement and gastrocolic fistula formation

Question 31

Purpose of propping patients up by at least 30 degrees whilst feeding and 30 mins after

Answer 31

To minimise the risk of aspiration Reflux occurs frequently(esp in patients with impaired consciousness, poor gag reflex and when fed in the supine position)

Question 32

GI symptoms of enteral feeding

Answer 32

``` Abdominal bloating Cramps Nausea Diarrhoea Constipation ```

Question 33

Monitoring for enteral feeding

Answer 33

Position of nasally inserted tubes, which should be checked before each feed by obtaining tube aspirate of pH < 5.5 on pH paper Development of erosions Gastrostomy and jejunostomy stoma sites should be checked for infection