nutritional support Flashcards
(36 cards)
reasons for malnutrition (7)
N/V/D: drug induced or chemo
Changes in appetite: chemotherapy, Mg deficiency
Early satiety: ascites (full after small meal, due to fluid in abdomen)
Malabsorption: IBD (↓ area for absorption due to surgical resection)
Nutrient loss: dialysis
Impaired metabolism: stress, trauma, pregnancy, wound healing
Reduced volitional intake: delirium, poor dentition
complications from malnutrition (6)
Poor wound healing
Compromised immune status
Impairment of organ function
↑ use of healthcare resources
↑ mortality
↑ complications
Nutritional screenings
to identify individuals at risk (higher score = bad)
○ Unintentional weight loss in past 6 months
○ Nutritional intake in past 1 week
○ Muscle wastage (from temple / clavicle bone)
Nutritional assessments (2)
● Nutritional assessment:
○ Anthropometric: height, weight, BMI
○ Biochemical: electrolyte, albumin (lower in malnutrition)
○ Clinical: history (surgery), muscle stores (hand grip strength)
○ Dietary: how long malnutrition was, normal intake
● Seven-Point Subjective Global Assessment (1 = bad, 7 = good)
○ Weight loss in the past 6 months
○ Dietary intake in past 2 weeks
○ Gl symptoms (persisted > 2 weeks)
○ Functional status
○ Disease state affecting nutritional requirements
○ Muscle wastage / Fat stores / Edema (↓ dry weight)
energy requirements
25-35 kcal/kg body weight
How to measure total energy expenditure (TEE)
Total energy expenditure (TEE) = Resting Energy Expenditure (REE) / Basal Metabolic Rate (BMR) + Physical Activity
TEE = REE (BMR) x activity factor ( x disease-specific stress factor)
Modes of measurement of REE (2)
○ Indirect calorimetry (Gold): measurement of gas exchange
○ Predictive equations (only estimations)
Protein requirements
0.8 g/kg/day (healthy)
Trauma / surgery / burn / sepsis = 1.5-2 g/kg/day (up to 2.5)
CKD not on dialysis = 0.6-0.8
on HD/PD = 1.2 g/kg/day
Definition of enteral nutrition
Nutrition provided through the GIT via a tube, catheter, or stoma that deliver nutrients distal to the oral cavity
● For patients who are unable to receive adequate nutrition by oral route: swallowing impairment, mechanical ventilation, altered mental status, motility disorders
Different types of enteral access devices (4)
NG, PEG, NJ, PEJ
what is NG and what are the pros and cons
Feed into stomach, use more GIT
More physiologic (preferred)
↑ tolerance to bolus feeding (normal eating schedule)
↑ tolerance to enteral product (osmolarity, pH)
Used for venting (aspirate content through tube)
Cons: DON’T USE in patients with delayed gastric emptying
Vomit ↑ aspiration risk = NG tube draw out acid = ↓ vomit
what is NJ and what are the pros and cons
Feed into Jejunum, duodenum
● Smaller bore (narrow outlet btwn stomach & duodenum), less discomfort
● Can use in dysfunctionality in proximal GIT (delayed emptying or obstruction)
● Minimize aspiration risk
Cons: Higher risk of tube clogging
what is the preferred enteral route
NG, PEG
what are the 2 modes of entry for EN
nasal: not for long term, less comfortable, change every month
stomy: need surgery, long term, change every year
2 modes of intake for EN
Bolus: mimics oral intake (by gravity) & more physiologic, no pump, more freedom
Continuous: better tolerated, less aspiration risks, need pumps
types of EN nutrition (3) and egs
Modular: singular nutrient –> fortifier (eg. myotein: high whey after surgery, MCT oil: bypass lymphatic system, used in CHYLE [leakage in lymphatic drainage system]
Semi-elemental: partially hydrolysed nutrition –> for impaired GI function (eg. peptamen - metallic taste)
Polymeric: intact macro-nutrients –> req sufficiently functional GIT (eg. boost isocal - most isotonic, less osmotic diarrhea, ensure - clear fluids are more easily digested)
what is immune modulating/disease specific EN
specific addition / restriction of specific nutrients to meet needs for certain diseases (nepro?)
management of EN tolerance (5)
● Continuous instead of bolus
● Use of prokinetic (metoclopramide, domperidone, IV erythromycin)
● Post-pyloric feeding if intolerant to gastric feeding
● Use of isotonic formula (boost isocal)
● Semi-elemental / elemental feeds for malabsorption issues
drug-nutrient interactions for EN (4)
Inappropriate drug administration can cause:
○ Binding of medication to tube (e.g. phenytoin)
○ Medication-feed interaction (e.g. FQ → sep from Ca)
○ Alteration of dosage (e.g. Sustained-release, enteric coating)
Stop feedings, flush access device before and after drug with water (usually not an issue with bolus/intermittent feeding)
complications of EN (6)
ROTAIN
1. Refeeding syndrome
2. Occlusion of feeding tube
a. Jejunal > gastric tube (due to small bore)
b. Medication administration
c. Formula : concentrated / high protein / fibre-enriched
3. Tube displacement (due to vigorous coughing)
4. Aspiration
5. Infections (2nd to microbial contamination) → NO water to dilute
6. Nausea / vomiting / diarrhoea / constipation
monitoring of EN (6)
● Signs of intolerance (N/V/D)
● Gastric residual volume = amount aspirated from the stomach into feeding tube (high GRV = inability to empty stomach content downstream = GI dysfunction)
○ pH (1-2), consistency, colour
● Blood glucose level
● Electrolytes
● Fluid balance
● Weight (long-term)
5 benefits to using EN
○ Maintain functional integrity
○ 1st pass metabolism, promote efficient nutrient utilization,
○ Maintain normal gallbladder function,
○ Maintain gut-associated & mucosal-associated lymphoid tissue
○ Less complications than parenteral nutrition & less expensive
definition of parenteral nutrition + egs (4)
Patients who are unable to receive or tolerate adequate nutrition by the enteral route
○ Paralytic ileus
○ Small bowel obstruction
○ High output / proximal fistula
○ Mesenteric ischaemia
types of parenteral access devices
peripheral and central
