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Multi-morbid > Nutritional Support > Flashcards

Nutritional Support Flashcards

1
Q

What is dumping syndrome?

A

Rapid gastric emptying; when food moves from stomach to duodenum too quickly

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2
Q

Accessory organs of digestive system

A

liver, gallbladder, pancreas

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3
Q

Roles of GIT

A
  1. Digestion, absorption, excretion
  2. Secretion of fluids and enzymes
  3. Gut hormones (e.g. cholecystokinin CCK)
  4. Immune function
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4
Q

Stomach

A
  • stores food and secrete gastric digestive juices
  • pH 1.5-2.5; highly acidic environment for chemical breakdown of food and extraction of nutrients
  • release intrinsic factors for absorption of Vitamin B12
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5
Q

Duodenum (small intestine)

A
  • digestive juices from pancreas, liver and gallbladder; breaks down food particle in chyme into glucose, TGs and AAs
  • absorption of fatty acids
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6
Q

Where is bile produced?

A

Liver

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7
Q

Where is bile stored?

A

Stored and concentrated in gallbladder

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8
Q

Function of bile

A

Contains bile salts which emulsify lipids

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9
Q

Function of pancreas

A

Produces enzymes that catabolise starches, disaccharides, proteins and fats

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10
Q

Jejunum

A
  • bulk of chemical digestion and nutrient absorption
  • most of carbohydrates and AAs absorbed
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11
Q

Large intestine

A

reabsorb water from undigested food and process of waste material

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12
Q

Liver

A

Digestion of fats and detoxifying blood

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13
Q

What controls flow of food?

A

Spincter

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14
Q

How much fluid does stomach produce?

A

1-2L/day, containing enzymes, gastric acid and electrolytes

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15
Q

If patient has vomiting and diarrhoea, what has to be replenished?

A

fluids and electrolytes

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16
Q

Where is cholecystokinin produced?

A

Duodenum, in response to food passage

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17
Q

Function of cholecystokinin

A

Stimulates pancreatic contraction to release pancreatic enzymes into intestine
Stimulates liver to produce bile
Stimulates gallbladder to contract to release bile

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18
Q

If gallbladder is removed, what is the implication on patient’s diet?

A

low fat diet as bile digests fats

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19
Q

What happens to CCK without food?

A

CCK is not produced, gallbladder contraction will be impaired and biliary flow also impaired, resulting in cholestasis

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20
Q

Cause of malnutrition

A

Decreased intake/absorption
Increased expenditure losses

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21
Q

How does advanced abdominal cancer result in malnutrition?

A

Ascites presses on GIT → cause early satiaty (stomach cannot expand as much) → feels full faster → reduced intake

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22
Q

How do cancer chemotherapy result in malnutrition?

A

N/V and taste alterations

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23
Q

How do burns, trauma, sepsis result in malnutrition?

A

Increased body expenditure of energy consumption through wound healing and helping to fight infections

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24
Q

How do dialysis result in malnutrition?

A

Protein losses

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25
Q

Malnutrition leads to? -6

A
  1. Increased complications
  2. Poor wound healing
  3. Compromised immune status
  4. Impairment of organ functions
  5. Increased mortality
  6. Increased use of healthcare resources
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26
Q

Nutritional assessment during screening

A

ABCD
Anthropometric data (height, weight)
Biochemical data (electrolytes, serum albumin)
Clinical (PMH, physical examination)
Diet history

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27
Q

Is serum albumin an indicator of nutritional status?

A

Insufficient protein levels can lead to decreased production of albumin by liver, BUT can also be affected by inflammatory and fluid overload states

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28
Q

Screening tools

A

3-minute nutrition screening
- mainly in outpatient setting

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29
Q

3-MinNS scoring

A

≥3: nutritional risk
3-4: risk of moderate malnutrition
5-9: severe malnutrition

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30
Q

Nutritional assessment tool

A

Seven-Point Subjective Global Assessment (SGA)

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31
Q

SGA rating

A

7-6: well nourished
5-3: mildly to moderately malnourished
2-1: severely malnourished

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32
Q

How is energy usually calculated?

A

kcal

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33
Q

Total energy expenditure is dependent on?

A

Resting/basal metabolic rate, physical activity, stress factor

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34
Q

Modes of energy measurement

A
  1. Indirect calorimetry
  2. Weight-based
  3. Predictive equations
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35
Q

What is the gold standard to measure energy required?

A

Indirect calorimetry

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36
Q

How is indirect calorimetry conducted?

A

Collection of gas
C6H12O6 + 6O2 → ATP + 6CO2 + 6H2O

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37
Q

Weight based energy calculation

A

25-35kcal/kg for general hospitalised patients

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38
Q

Predictive equations only estimate ______.

A

Basal metabolic rate
Need to adjust for activity and stress factor

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39
Q

Protein requirement for healthy adult

A

0.8g/kg/day

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40
Q

Protein requirement for CKD not on dialysis patient

A

0.6-0.8g/kg/day

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41
Q

Protein requirement for patients on HD/PD

A

1.2g/kg/day

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42
Q

Protein requirement for patients on CRRT

A

Up to 2g/kg/day

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43
Q

Definition of Enteral Nutrition

A

Nutrition provided through the GIT via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity

44
Q

Indications for enteral nutrition - 4

A
  1. Swallowing impairment
  2. Mechanical ventilation
  3. Altered mental status
  4. Motility disorders
45
Q

Types of enteral assess devices

A

Pre-pyloric (NG, PEG)
Post-pyloric (NJ, PEJ)

46
Q

Advantages of NG tubes - 4

A
  1. More physiologic
  2. Higher tolerance to bolus
  3. Higher tolerance to wide range of enteral feeds
  4. May be used for venting
47
Q

Why is NG tube more physiological?

A

Bypasses less of GIT

48
Q

Why does NG tube have higher tolerance to bolus feeding?

A

Stomach acts as a reservoir

49
Q

Why NG tube has higher tolerance for feeds with higher osmolarity?

A

Stomach has higher fluid content than intestines

50
Q

When should NG tube not be used?

A

Patients with delayed gastric emptying

51
Q

What is the risk caused by more gastric fluid?

A

More gastric fluid increases risk of vomiting, which increases risk of aspiration pneumonia

52
Q

Advantage of NJ tube

A
  1. Narrower diameter, less discomfort
  2. Minimise aspiration risk
53
Q

When can NJ tube be used?

A

In conditions that result in dysfunctionality in proximal GIT

54
Q

Disadvantage of NJ tube

A

Higher risk of tube clogging

55
Q

Modes of enteral feed administration

A

Bolus and Continuous

56
Q

Is bolus or continuous feeding better tolerated?

A

Continuous

57
Q

Does bolus or continuous feeding have lower risk of aspiration?

A

Continuous

58
Q

Advantage of bolus administration of enteral feeds?

A
  • No pump required
  • Greater freedom for ambulation
59
Q

Types of EN formula

A
  1. Modular
  2. Semi elemental
  3. Polymeric
  4. Immune-modulating/ Disease-specific
60
Q

Modular

A
  • single nutrients
  • used as fortifier; not meant to be a meal replacement
61
Q

Long chain TG will first be absorbed into?

A

Lymphatic system

62
Q

Medium chain TG will first be absorbed into?

A

Bloodstream

63
Q

Semi elemental

A
  • Partially/completely hydrolysed nutrients
64
Q

Which patient group is semi elemental EN for?

A

Patients with impaired GI function, impaired tolerance to standard feeds

65
Q

Semi elemental EN is often high in _____?

A

Osmolarity; can cause diarrhoea

66
Q

Polymeric

A

Intact MACROnutrients

67
Q

What is required for polymeric EN?

A

Sufficiently functional GIT

68
Q

Main feature of Glucerna

A

Low glycemic index

69
Q

Main feature of Presubin Protein Energy

A

High protein

70
Q

Main feature of Nepro HP

A

High protein

71
Q

Main feature of Nepro LP

A

Low protein, K, P

72
Q

Main feature of NutriFriend

A

Contains omega-2-fatty acids: EPA/DHA

73
Q

Does patient on dialysis require high or low protein intake?

A

High

74
Q

Which route of administration is drug-nutrient interaction for EN more commonly associated with?

A

Continuous

75
Q

Administration of incompatible drugs with EN may cause?

A
  1. Precipitation
  2. Curdling, clumping of protein
  3. Alteration of dosage form
76
Q

When does curdling, clumping of protein occur?

A

In contact with acid

77
Q

What drug is known to chelate with cations like calcium?

A

FQ - Ciprofloxacin

78
Q

How to prevent/mitigate drug-nutrient interaction with EN?

A
  1. Stop feeding, flush access device before and after drug administration
  2. Therapeutic alternatives available in appropriate dosage form
79
Q

Common complications of EN

A
  1. Occlusion of feeding tube
  2. Tube migration
  3. Infection secondary to microbial contamination
  4. Aspiration
  5. N/V
  6. D/C
  7. ***** Refeeding syndrome
80
Q

Is occlusion of feeding tube more common in NG or NJ tube?

A

Jejunal due to smaller diameter

81
Q

What kinds of EN formula is more likely to cause occlusion of tube?

A

Concentrated
High protein
Fibre-rich

82
Q

How to maximise tolerance to EN?

A
  1. Continuous instead of bolus
  2. Use pro kinetic agents
  3. Post-pyloric feeding if intolerant to gastric feeding
  4. Use isotonic formula
  5. Semi elemental or elemental feeds for patients with malabsorption issues
83
Q

Which pro kinetic agents can be used to maximise tolerance to EN?

A

Metoclopramide
Domperidone
IV Erythromycin

84
Q

Indications of parenteral nutrition

A

For patients who are unable to receive or tolerate adequate nutrition by the enteral route
- Paralytic ileus
- Small bowel obstruction
- High output/ proximal fistula
- Mesenteric ischemia

85
Q

Types of parenteral access devices

A
  1. Peripheral
  2. Central
    - Non-tunneled central venous catheter
    - Tunneled central venous catheter
    - Peripherally inserted central catheter (PICC)
    - Port-a-Cath
86
Q

Non-tunelled central venous catheter

A
  • Short tube
  • Short lived for ≤2w
  • Highest risk of infection
87
Q

Limitation of peripheral access for PN

A

Frequent resite (q72hrs)
Osmolarity (~900)
- If too high, patient will complain of swelling and pain

88
Q

Composition of PN

A

Nutrition in its simplest, most elemental form
- Complex sugars →
Dextrose
- Protein → AA
- Fats → TG

89
Q

Total parenteral nutrition vs total nutrition admixture

A

TPN does not contain lipid

90
Q

Administration of incompatible drugs may cause?

A
  1. Precipitation
  2. Loss of drug activity
  3. Phase separation of lipid emulsions
  4. Toxicity
91
Q

Device-related complications for PN

A
  1. Occlusion in IV catheter
  2. Mal positioning
  3. Catheter-related bloodstream infection
92
Q

What can cause occlusion in IV catheter?

A
  1. Thrombosis/clotting
  2. Inappropriate flushing technique
  3. PPT due to drug incompatibilities, crystallisation
  4. Lipid residues
93
Q

If PN contains lipid, change administration set every _____ hours.

A

24 hours

94
Q

Metabolic complications of PN

A
  1. Refeeding syndrome
  2. Hyper/hypoglycaemia
  3. Fluid overload
  4. Intestinal failure associated liver disease (IFALD)
  5. Metabolic bone disease
95
Q

How is PN associated with IFALD?

A
  1. Prolonged NIL-BY-MOUTH
  2. Fatty liver if overfeeding patient
  3. Type of TG being fed to patient
96
Q

MOA of prolonged nil-by-mouth

A

Lack of CCK → impaired bile flow →
cholestasis

97
Q

MOA of TG fed to patient

A

LCT is pro-inflammatory and precursor of inflammatory markers → giving pure MCT/LCT over prolongedperiods of time may thus cause liver damage

98
Q

How does newer lipid formulation helps with prevention of IFALD

A

Newer lipid formulations have SMOF – Soybean (LCT), MCT, Olive oil,
Fish oil → Fish oil balances effects of LCT as it is anti-inflammatory

99
Q

What is the hallmark of refeeding syndrome?

A

Hypophosphataemia

100
Q

Refeeding causes increase in?

A

Insulin secretion, which leads to increased glucose uptake, increased utilisation of thiamine, increased uptake of K, Mg, PO

101
Q

Signs and symptoms of refeeding syndrome

A

Hypokalemia
Hypomagnesaemia
Hypophosphataemia
Thiamine deficiency
Salt and water retention (oedema)

102
Q

Management of Refeeding Syndrome

A

1.Identify high risk patients
2. Check serum electrolytes at baseline
3. Correct deficiency prior to feeding, defer if electrolytes critically low
4. Administer thiamine supplement
5. Initiate feeding slowly (40-50% energy requirements), gradually increase over next few days
6. Continue to monitor electrolytes, adjust replacement if needed

103
Q

Ethical guiding principles in nutritional support

A

Autonomy
Beneficence
Non-maleficence
Justice

104
Q

Dietary advice

A
  1. Take small frequent meals with snack in between
  2. Consume more protein/caloric dense foods
  3. Choose soft, low fibre foods
  4. Trying out various oral nutritional supplements to see if taste palatable
105
Q

Dose of thiamine supplement

A

100mg OD for 5 days

106
Q
A

Multi-morbid (5 decks)

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