Enteral and Parenteral Nutrition
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What is the general indication for both enteral and parenteral nutrition?
EN: Hemodynamically stable pt AT RISK of malnutrition, who its anticipated that oral feedings will be inadequate for at least 1-2 wks
PN: IV nutrition for pt w/nonf(x)ing or inaccessible GI tract and is anticipated that PN is needed for at least 7 days
Wut r the 6 contraindications for use of EN?
- Complete intestinal obstruction
- GI fistula
- Extreme short bowel
- Severe V or D
- Hemodynamic instability or intestinal ischemia
- Paralytic ileus
Wut are the 6 administrative tubes for EN?
-Which is preferred for those w/nasal or facial trauma?
-Which is most common for short-term enteral access?
-Which is tolerant to pts w/gastric ileus?
-Which is preferred for long-term feeding?
-Which is used for immediate post-op or postinjury feeding?
- 1. Orogastric - preferred for those w/nasal or facial trauma
- 2. NG - most common for short-term enteral access
- 3. Nasoduodenal - tolerant to pts w/gastric ileus
- 4. Nasojejunal
- 5. Gastrostomy - preferred for long-term feeding
- 6. Jejunostomy - used for immediate post-op or postinjury feeding
Intermittent bolus feedings of 100-300ml for 30-60mins q4-6hrs can only be used for feeding tubes ending in the _________
Intermittent bolus feedings of 100-300ml for 30-60mins q4-6hrs can only be used for feeding tubes ending in the stomach
Why is EN preferred in pt w/f(x)al GI tract over PN?
EN Asso'd w/lower risk of infx than PN
EN formulations typically include what 7 general things?
- 1. Carbs
- 2. Fat
- 3. Protein
- 4. Electrolytes
- 5. Water
- 6. Vitamins
- 7. Trace elements
Wuts the diff b/w intact/polymeric and elemental formulas for EN?
Intact/polymeric are for normal digestive processes
Elemental formulas are easily digested by pt w/impaired digestive capacity or malabsorption (ie short bowel, pancreatic insuff)
What varying amts of substance is in EN for renal failure? (2)
Typically more concentrated (i.e. 2kcal/ml vs 1kcal/ml in intact formulas) for fluid restricted pt
And reduced amt of protein and electrolytes in nondialysis pt
What varying amts of substance is in EN for resp failure?
More calories from fat and fewer from dextrose to reduce prod of CO2 frm dextrose
FYI Excessive CO2 prod is from overfeeding with TOTAL calories rather than total amt of dextrose so these formulations may be unnecessary
What varying amts of substance is in EN for diabetic pts? (2)
More calories frm fat rather than frm carbs
Added fiber to improve glycemic control
What varying amts of substance is in EN for hepatic failure and hepatic encephalopathy?
More branched-chain AA and less aromatic AA which may improve encephalopathy (although controversial)
What varying amts of substance is in EN for highly stressed pt (trauma, burns, acute resp distress syndrome, sepsis)? (6)
- EN enhanced w/..
- 1. Protein
- 2. Arginine
- 3. Glutamine
- 4. Omega-3 FAs
- 5. Nucleotides
- 6. Beta-carotene
FYI designed 2 enhance immune f(x) and clinical outcomes
To avoid clogged feeding tubes with EN, when should tubes be flushed?
What are unclogging solutions that r suggested? (4)
Flush tubes b4, b/w, and after admin of each drug
- Unclog with:
- 1. Warm water
- 2. Cola
- 3. Pancreatic enzymes
- 4. NaHCO3
Wut r 4 ways to prevent aspiration pneumonia in EN feeding pts?
1. Elevate head of bed at 30-45 degrees
2. Monitor gastric residuals, d/c if vol>250-500ml
3. Administer EN past the pyloric valve using duodenal feeding tube
4. Initiate at a slow rate of 20ml/hr and advance q4-6hrs as tolerated to goal rate
Hypernatremia typically occurs w/AMS in pt receiving EN. How can one prevent this?
Req 1ml of H2O per calorie (ie calorie-dense formulas have 2kcal/ml)
When monitoring EN and gastric residuals are being checked, infusion rate is generally held or reduced if residual amt exceeds _______ml in gastric tube feeds only.
- When monitoring EN and gastric residuals are being checked, infusion
- rate is generally held or reduced if residual amt exceeds 250-500ml in
- gastric tube feeds only.
What are the 5 steps to help determine an EN regimen?
1. Determine caloric requirements [25-30kcal/kg/d]
2. Choose a EN formula and assess calories/ml [usually 1, 1.2, 1.5, or 2kcal/ml]
3. Determine infusion rate [(vol of EN)/24hrs]
4. Make sure pt will receive enough protein (check package info)
5. Make sure pt will receive 1ml water for each calorie (to prevent hyperNa)
How much water should be flushed before and after each drug administration for EN?
20ml water flushed b4 and after drug admin
To prevent reduced bioavailability, what 4 drug/drug classes warrant the need to temporarily dc tube feedings before and after their EN administration?
Wut r the 7 indications for PN?
1. Severe pancreatitis
3. Severe IBD
4. Extensive bowel resection causing malabsorption
5. Complete bowel obstruction
6. Severe intractable V/or D
7. Inability to meet full nutritional needs by enteral route alone (Can use PN as supplement to EN)
PN is usually administered through a _______ line. If another line, _____________ must be used, osmolarity must not exceed _______mOsm/L. This admin access can be used if PN is expected to be <2wks.
- PN is usually administered through a central line. If another line,
- peripheral access must be used, osmolarity must not exceed 900 mOsm/L.
- This admin access can be used if PN is expected to be <2wks.
If a peripheral line MUST be used for PN, the final percentage concentrations of dextrose and AA should be....? Final concentrations of Ca and K should be....?
- [Dex] 10% or less
- [AA] 2.5-4%
- [Ca] 5mEq/L or less
- [K] 40mEq/L or less
Wut is the estimated osmolarity of:
Lipid emulsion 20%
Acronym: All Dexter Saw - Polices' Lips Can Magnify
- AA - 10mOsm/L
- Dextrose - 5mOsm/L
- Sodium - 2mOsm/L
- Potassium - 2mOsm/L
- Lipid emulsion 20% - 1.3-1.5mOsm/L
- Calcium gluconate - 1.4mOsm/mEq
- Magnesium sulfate - 1mOsm/mEq
For PN admixture bags, what is the difference in nutrients for 2-in-1 and 3-in-1 PN? Wuts the diff in changing of admin tubes?
- 2-in-1 PN: All nutrients EXCEPT lipids [fyi lipids admin in diff tubing]
- Admin tube should be changed every 72hrs
- 3-in-1 PN: All nutrients mixed to form lipid emulsion
- Admin tube should be changed every 24hrs
Wut r the usual available concentrations of the following for PN? How many calories/g do they provide?
Dextrose: 70%; 3.4kcal/g
Glycerol: Unspecified; 4.3kcal/g
Fat emulsion:10-20%; 10kcal/g
AA: 3-20%; 4kcal/g
What are the 4 general steps to developing a PN regimen (not including electrolytes or trace elements)?
1. Determine caloric requirement (using BMI)
2. Determine fluid requirements [1500ml (1st 20kg) + [(20ml/kg x kg) for add'l kg]
3. Determine AA requirements (using BMI and protein-restricted needs or stress level)
4. Calculate remaining calories, admin 20-30% of total calories as lipids and remainder as dextrose
Regarding adding trace elements to PN, wut would pts benefit from if they had high-output fistulas, diarrhea, burns, or large open wounds?
Regarding adding trace elements to PN, wut would pts benefit from if
they had chronic diarrhea, malabsorption, or short-gut syndrome?
Regarding trace elements in PN, wut 2 elements would pts need a restriction of if
they had severe cholestasis and holding them would prevent accumulation and toxicity (b/c both undergo biliary elimination)?
Wut r the 8 steps and the order of mixing nutrients for PN?
1. Add dextrose, AA, sterile H2O
2. Add PO4
3. Add other electrolytes (except Ca) and trace minerals
4. Mix well to ensure PO4 is evenly distributed and to prevent ppt with Ca
5. Add Ca
6. Observe for ppt's or contaminates
7. Add lipid if 3-in-1 formula (FYI avoid adding dex and lipid 2gether b/c low pH of dex and destabilize lipids. Also 2-in-1 PN have separate line for lipids)
8. Add vitamins last, right before infusion
Wut r the 7 ways to prevent Ca and PO4 precipitation in PN?
1. Decrease pH of formula by ensuring final [AA] is at least 2.5% or more (acidity...)
2. Ensure Ca is 6mEq/L or less AND PO4 30mmol/L or less
3. Use Ca gluconate and NEVER CaCl
4. Increased T worsens, so refrigerate w/in 24hrs of compounding and administer w/in 24hrs of rewarming
5. Use 1.2 micron filter in 3-in-1 PN
6. Agitate often while compding 4 adequate mixing
7. Add PO4 b4 Ca
In general, adding meds to PN should be avoided if possible but if it must be done, flush with ____ml of water before and after drug admin (compared to 20ml H2O for EN). Wut r 8 drugs to definitely avoid adding to PN?
Flush with 10
ml of water before and after drug admin (compared to 20ml H2O for EN)
- Iron Dextran
What are two bugs that primarily cause catheter-related infx in PN?
Peripheral venous thrombophlebitis can occur w/peripheral catheter placement. Therefore, site rotation should occur every _______
- Peripheral venous thrombophlebitis can occur w/peripheral catheter
- placement. Therefore, site rotation should occur every 3 days
What types of excessive salts may cause in PN:
Metabolic acidosis: Excessive Cl salts
Metabolic alkalosis: Excessive acetate salts
Overfeeding in PN can cause what 4 conditions?
Hypercapnia (elevated CO2)
Azotemia (elevated N)
Essential FA deficiency can cause skin desquamation, hair loss, impaired wound healing, hepatomegaly, thrombocytopenia, fatty liver, and anemia. This can occur w/in 1-3 wks of a formula of _________ PN.
- Essential FA deficiency can cause skin desquamation, hair loss, impaired
- wound healing, hepatomegaly, thrombocytopenia, fatty liver, and anemia.
- This can occur w/in 1-3 wks of a formula of lipid-free PN.
Refeeding syndrome can occur in acute or chronic malnourished in both EN and PN. Its characterized by what 3 "hypo's"?
What r 3 ways to prevent refeeding syndrome?
1. Id pt's at risk (anorexia, alcoholism, cancer, chronically ill, poor nutritional intake x1-2wks, recent unintentional wt loss, malabsorption)
2. Provide <50% caloric requirements n advance over several days to goal
3. Supplement vitamins b4 initiating PN as well as K, PO4, and Mg
What are 3 general conditions/disorders that may occur with long-term PN?
1. Aluminum toxicity (more likely in renal dysf(x))
2. Hepatobiliary disorders (steatosis, cholestasis, gallbladder sludges or stones)
3. Osteoporosis/osteomalacia (asso'd w/higher protein doses which inc Ca excretion)
Wut r 3 general labs that should be monitored and 1 physical monitoring parameter in PN?
- 1. Infx (T, WBC, IV access site)
- 2. Fluid status (wt, edema, vital signs, ins n outs)
- 3. Nutritional status - Prealbumin (Nl: 16-40; Severe malnutrition: <11)
- Monitor for peripheral vein thrombophlebitis (rotate site q3d)
Why is serum albumin a poor predictor of nutritional status in PN? (2)
Serum albumin (3.5-5) has a long t1/2 and concentrations fluctuate during illness
Wuts a common BG goal in PN when monitoring for hyper and hypoGLY?
Wut type of insulin can be mixed into PN? Abrupt dc of PN is not tolerable in which pts?
Regular insulin can be mixed into PN
Abrupt dc not tolerable in diabetic pts so taper off slowly
If PN patients have the following disorders, what generally can be done?
Metabolic acidosis: Administer Na or K acetate
Metabolic alkalosis: Administer Na or K Cl
Respiratory acidosis/alkalosis: Correct underlying cause (overfeeding?) or adjust ventilator setting as needed
When monitoring TG concentrations, withhold lipids in pts w/TG over....?
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