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PR4152: Multi-morbid patients > Supportive and Palliative Care (Nutrition) > Flashcards

Supportive and Palliative Care (Nutrition) Flashcards

1
Q

Causes of malnutrition

A

Decrease intake absorption:
- Cancer → loss of appetite, taste changes. N/V
- Dialysis
- Malabsorption due to surgery
- Advanced abdominal cancer and ascites
- Stress: burns, trauma, surgery

Increased expenditure losses

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2
Q

Effects of malnutrition

A

Increased complications
Poor wound healing
Compromised immune status
Impairment of organ functions
Increased mortality
Increased use of healthcare resources

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3
Q

What are the four steps done during nutritional screening and assessment

A
  1. Nutritional screening
  2. Refer to dietitian/nutritional specialist
  3. Nutritional assessment
    An in depth, systemic process that integrates and interpret pt data to identify nutrition-related problems
    A: Anthropometric- height, weight
    B: Biochemicals- electrolytes, albumin (low)
    C: Clinical- Hx, physical exam
    D: Diet
  4. Formulation of nutritional regime
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4
Q

What is a common nutritional assessment used

A

Seven-point subejctive global assessment (SGA)

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5
Q

What is total energy expenditure dependent on?

A

resting/basal metabolic rate, physical activity, stress factor

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6
Q

What are the 3 modes of measurement for energy?

A
  1. Indirect calorimetry
  2. Weight based
  3. Predictive equations (schofield and harris-benedict eqn)
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7
Q

How does indirect calorimetry measure energy?

A

Measurement of gas exchange during consumption of substrates to produce required energy

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8
Q

How does weight based measurements measure energy

A

25-35 kcal/kg for general hospitalized patients (ESPEN)

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9
Q

What is the disadvantage of using predictive equations to measure energy?

A

Only estimates basal metabolic rate so need to adjust for activity and stress factor
Lower accuracy than calorimetry but is most commonly used in clinical setting

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10
Q

Which mode is the gold standard for measuring energy

A

Indirect calorimetry but it is tedious so not commonly used

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11
Q

What are the protein requirements for different individuals (healthy, CKD pts)

A

Healthy: 0.8g/kg/day
CKD:
- Not on dialysis: 0.6-0.8g/kg/d
- HD/PD: 1.2g/kg/d -> protein is lost during HD/PD
- CRRT: Up to 2g/kg/d

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12
Q

What is enteral nutrition?

A

“Nutrition provided through the gastrointestinal tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity.” - ASPEN

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13
Q

What are some examples where enteral nutrition is used?

A

For patients who are unable to receive/tolerate adequate nutrition by the oral route

Examples:
Swallowing impairment eg. post stroke
Mechanical ventilation eg. have tube for breathing alr
Altered mental status eg. lose consciousness
Motility disorders eg. gastroperesis (diabetes)

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14
Q

What are the types of enteral access devices?

A

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

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15
Q

Which enteral access devices is preferred and why?

A

Pre-pyloric:
- More physiologic: maximise potential of GIT.
- Higher tolerance to bolus feeding
- Higher tolerance to a wide range of enteral products
- May be used for venting

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16
Q

When is pre-pyloric devices not used?

A

Pts with delayed gastric emptying

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17
Q

When is post-pyloric devices used and why?

A

Only used in conditions that result in dysfunctionality in proximal GIT due to high risk of tube clogging

18
Q

What is the advantage of using post-pyloric devices

A

Smaller bore so less discomfort
Minimize aspiration risk

19
Q

When is stomy tubes used over nasal tubes?

A

Inserting stomy tube is a small surgical procedure so it is more difficult to insert and remove. The wound may not heal after removing so it is more for pts that need it for lifelong

20
Q

What are the 2 modes of administering enteral feeds and which is better tolerated and why?

A

Bolus:
Usually by gravity- mimics oral intake
More physiologic
No pump required, just pour
Greater freedom for ambulation

Continuous:
Pump assisted delivery at a constant rate
Better tolerated- Split into smaller meals so less bloated
Lower risk of aspiration

21
Q

What are the 4 types of EN formulas and their compositions?

A

Modular:
Contains single nutrient
Used as fortifier to enhance a specific nutritional component / augment oral diet
Not meant as meal replacement

(Semi) elemental:
High osmolarity → diarhhoea
Contains partially/ completely hydrolyzed nutrients
For patients with impaired GI function, impaired tolerance to standard feeds

Polymeric:
Contains intact macronutrients eg. complex sugars etc
Requires sufficiently functional GIT

Immune-modulating/disease-specific:
Contains additions / restrictions of specific nutrients to meet needs for disease management
May or may not meet individual’s full nutritional needs

22
Q

Provide some examples for the different types of EN formula

A

Modular: Myotein, valens enersus
Semi-elemental: peptamen
Polymeric: Ensure, resource fruit, boost
Disease-specific:
- Diabetes: glucerna
- Increased protein: Fresubin
- CKD: Nepro
- Infl. disease/cancer: NutriFriend

23
Q

What is the consequences of drug interactions with EN formulas?

A

Precipitation
Curdling, clumping of protein
Alteration of dosage form (e.g. sustained/modified release/enteric coated)

24
Q

How to prevent and mitigate drug-nutrient interactions

A

Stop feeding, flush access device before and after drug administration
Use therapeutic alternatives available in appropriate dosage form

25
Q

What are common complications of enteral feeding

A
  1. Occlusion of feeding tube (if nvr flush properly esp small bore)
    - Jejunal > gastric tube
    - Medication administration
    - Formula – concentrated/high protein/fibre-enriched
  2. Tube migration: when pt coughs
  3. Infections secondary to microbial contamination
  4. Aspiration
  5. Nausea/vomiting
  6. Diarrhea/Constipation
  7. Refeeding syndrome
26
Q

What are some strategies to maximise tolerance to EN

A
  • Continuous instead of bolus
  • Use of prokinetic agents (e.g. metoclopramide, domperidone, IV erythromycin)
  • Post-pyloric feeding if intolerant to gastric feeding eg. gastroperesis
  • Use of isotonic formula (e.g. boost isocal)
  • Semi-elemental/elemental feeds for patients with malabsorptive issue (e.g. short bowel syndrome)
27
Q

What are some advantages of enteral feeding

A
  • Maintain functional integrity of the gut
  • Undergo first-pass metabolism, promote efficient nutrient utilization
  • Maintains normal gallbladder function
  • Maintain gut-associated and mucosal-associated lymphoid tissues
  • Less complications than PN – e.g. line related sepsis, IFALD
  • Less expensive
28
Q

What are some indications for parenteral nutrition?

A

For patients who are unable to receive or tolerate adequate nutrition by enteral route

Examples:
- Paralytic ileus: dismotility of intestines
- Small bowel obstruction
- High output / proximal fistula
- Mesenteric ischemia: blood vessel supply to intestine is compromised

29
Q

What are the two types of parenteral access?

A

Peripheral: Tip position is located outside of central vessels
Central: Position of catheter tip is in large bore blood vessel e.g. distal superior vena cava, inferior vena cava, right atrium

30
Q

What are two differences btw the different parenteral accesses

A

Peripheral:
Requires frequent re-site (every 72hrs)
Nutrient delivery limited by osmolarity and concentration

Central:
Can be used for longer term care (dont need re-site so frequently)
Blood flow is very high so can give more nutrients in smaller volume

31
Q

4 Examples of central catheters

A
  1. Non-tunnelled central venous catheter
    - Max 2wks, tube is short so highest risk of infection
  2. Tunnelled central venous catheter
    - Go under skin so lesser infection
  3. Peripherally inserted central catheter (PICC)
  4. Port-a-cath: For cancer pts on chemo
32
Q

What does parenteral nutrition composed of

A

Nutrition in its simplest, most elemental form and admixture of multiple components eg. dextrose solution, a.a, electrolytes, lipid emulsion

33
Q

What are some major concerns of parenteral nutrition composition?

A

Stability and compatibility

34
Q

What are the consequences of drug interactions with PN

A

Precipitation
Loss of drug activity
Phase separation of lipid emulsions: cause cracking
Toxicity

35
Q

How to prevent and mitigate drug-nutrient interaction with PN

A
  • Administer via separate peripheral IV cannula
  • If needed, pause PN administration, flush access device before and after drug administration before resuming PN infusion
36
Q

What are some device related complications of PN devices

A
  1. Occlusion in IV catheter
    - Thrombosis / clotting
    - Inappropriate flushing techniques
    - Precipitates as a result of drug incompatibilities, crystallization
    - Lipid residues
  2. Mal-positioning
  3. Catheter-related bloodstream infection (CRBSI)
37
Q

What are some metabolic complications of PN

A
  1. Refeeding syndrome
  2. Hyper/hypoglycemia
  3. Fluid overload
  4. Intestinal failure associated liver disease (IFALD)
    - Associated with prolonged not eating
  5. Metabolic bone disease: osteomalacia
38
Q

Pathophysiology of refeeding syndrome

A

Malnutrition –> body draws electrolytes from intracellular stores and reduces renal excretion –> causes hypoK, hypoMg, hypoP, edema and thiamine deficiency.

39
Q

How to manage refeeding syndrome

A
  1. Identify high risk pts
  2. Check serum electrolytes at baseline
  3. Correct deficiencies prior to feeding, defer feeding if electrolytes are critically low
  4. Administer thiamine (Vit B1) supplement
  5. Initiate feeding slowly and gradually increase over next few days to meet nutritional requirements (Start low and go slow!)
  6. Continue to monitor electrolytes as feeding progresses, adjust amount of replacements as needed
40
Q

According to NICE guidelines, what is the criteria for high risk patients for refeeding syndrome

A

One of the following:
BMI <16
Unintentional weight loss >15% in past 3-6m
Little or no nutritional intake >10d
Low K, Mg, P before feeding

OR

> =2 of the following:
BMI <18.5
Unintentional weight loss >10% in past 3-6m
Little or no nutritional intake >5d
Hx of alcohol misuse or drugs incl insulin, chemotx, antacids or diuretics.

41
Q

What is the activity factor for little or no exercise when calculating energy using predictive equations?

A

1.2

42
Q

What is the stress factor for cancer when calculating energy using predictive equations?

A

1.1-1.5

PR4152: Multi-morbid patients (5 decks)

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