B5: Clin Med Exam 3 pt 1

if the gut works, USE IT!

The main tenet of nutrition support is __________ BECAUSE:

-preserves mucosal barrier function + integrity

-attenuates the catabolic response and preserves immunologic function

-decreased incidence of hyperglycemia (compared to parenteral nutrition)

nutrition support

What is the delivery of formulated enteral or parenteral nutrients for the purpose of maintaining or restoring nutritional status?

enteral nutrition

What type of nutritional support:

-nutrition provided through GI tract via catheter, tube, or stroma

-provides nutrition distal to oral cavity

-provides many physiologic, metabolic, safety, and cost advantages over parenteral nutrition and SHOULD BE UTILIZED WHEN POSSIBLE

INDICATIONS: can use the GI tract

1. inability to eat = dysphagia, facial/oral/esophageal trauma/injury, congenital anomalies, on a ventilator, comatose, premature

2. inability to eat ENOUGH = cancer, HF, congenital heart disease, impaired intake, anorexia, HIV/AIDS, FTT, CF

3. impaired digestion, absorption, metabolism = severe gastroparesis, inborn errors of metabolism, Crohn's disease, short bowel syndrome w/ minimum resection, pancreatitis

nutrition support

ASPEN guidelines states to initiate _________ when pt is expected to (or has) not received adequate oral intake for 7-14 days. Pts who are malnourished or stressed mare require earlier initiation.

diarrhea

What is the most common reported GI complication for tube feeding (enteral nutrition) pts?

Hint: like from medications (e.g., sorbitol-containing solutions, ABx), C. diff, underlying or unrecognized GI disorders, and sometimes rate of tube feeding delivery

a.

What type of complication of enteral nutrition:

• Pressure necrosis/ulceration/stenosis

• Tube displacement/migration

• Tube obstruction

• Leaking from ostomy/stoma site

a. access problems

b. administration problems

c. GI complications

d. metabolic complications

b.

What type of complication of enteral nutrition:

• Regurgitation

• Aspiration

• Microbial contamination

a. access problems

b. administration problems

c. GI complications

d. metabolic complications

c.

What type of complication of enteral nutrition:

• Nausea/vomiting/constipation

• Diarrhea (osmotic, secretory, medications, treatment/therapy, hypoalbuminemia, maldigestion/malabsorption, formula choice/rate of administration

• Distention/bloating/cramping

• Delayed gastric emptying

a. access problems

b. administration problems

c. GI complications

d. metabolic complications

d.

What type of complication of enteral nutrition:

• Refeeding syndrome

• Drug-nutrient interaction

• Glucose intolerance/hyperglycemia/hypoglycemia

• Hydrations status - dehydration/ overhydration

• Hyponatremia

• Hyperkalemia/hypokalemia

• Hyperphosphatemia/hypophosphatemia

• Micronutrient deficiencies

a. access problems

b. administration problems

c. GI complications

d. metabolic complications

parenteral nutrition

What type of nutritional support:

-provision of nutrition IV (peripheral or central v.) in pts whose GIT is NOT FUNCTIONAL, ACCESSIBLE, OR SAFE TO USE

-complex admixture of AAs, dextrose, fat emulsions, H2O, electrolytes, vitamins, minerals, and trace elements

-exact route will depend on length of therapy, nutrition requirements, goal of nutrition therapy, availability of IV access, severity of illness, and fluid status

INDICATIONS: cannot use the GIT!!!!!

1. GI incompetency = Short bowel syndrome, severe inflammatory bowel disease, small bowel ischemia, severe liver failure, persistent postoperative ileus, distal high-output fistula, severe GI bleed, intractable vomiting/diarrhea

2. Critical illness w/ poor enteral tolerance of accessibility = Multi-organ system failure, major trauma, bone marrow transplant

a.

What type of complication of parenteral nutrition:

- Catheter entrance site

- Catheter seeding from blood borne or distant infection

- Contamination during insertion

- Long-term catheter placement

- Solution contamination

a. infection and sepsis

b. GI complications

c. mechanical complications

d. metabolic complications

b.

What type of complication of parenteral nutrition:

- Cholestasis

- Gastrointestinal villous atrophy

- Hepatic abnormalities

a. infection and sepsis

b. GI complications

c. mechanical complications

d. metabolic complications

c.

What type of complication of parenteral nutrition:

- Air embolism

- Arteriovenous fistula

- Brachial plexus injury

- Catheter fragment embolism

- Catheter misplacement

- Cardiac perforations

- Central vein thrombophlebitis

- Endocarditis

- Hemothorax, hydrothorax, pneumothorax or tension pneumothorax

- Hydromediastinum

- Subcutaneous emphysema

- Subclavian artery injury

- Subclavian hematoma

- Thoracic duct injury

a. infection and sepsis

b. GI complications

c. mechanical complications

d. metabolic complications

d.

What type of complication of parenteral nutrition:

- Dehydration from osmotic diuresis

- Electrolyte imbalance

- Essential fatty acid deficiency

- Hyperosmolar, nonketotic, hyperglycemic coma

- Hyperammonemia

- Hypercalcemia, hypocalcemia

- Hyperchloremic metabolic acidosis

- Hyperlipidemia

- Hyperphosphatemia, hypophosphatemia

- Hypomagnesemia

- Rebound hypoglycemia

- Uremia

- Trace mineral deficiency

- Metabolic bone disease (long-term use)

- Liver disease (long-term use)

a. infection and sepsis

b. GI complications

c. mechanical complications

d. metabolic complications

a.

Complications of overfeeding which macronutrient involves:

-hyperglyceemia, hyperinsulinemia

-Lungs: ↑ CO2 production, ↑ minute ventilation, contributes to respiratory failure, prolonged mechanical ventilation

-Liver: fatty deposition, hepatomegaly, cholestasis

a. carbs

b. fats

c. proteins

d. minerals

e. vitamins

b.

Complications of overfeeding which macronutrient involves:

- impaired TG clearance, fat overload syndrome

a. carbs

b. fats

c. proteins

d. minerals

e. vitamins

c.

Complications of overfeeding which macronutrient involves:

- ureagenesis --> renal function impairment

a. carbs

b. fats

c. proteins

d. minerals

e. vitamins

refeeding syndrome

What disorder:

-caused by aggressive administration of nutrition in malnourished individuals

-leads to rapid infusion of carbs which stimulates insulin release --> rapid uptake of glucose, K+, P, and Mg2+ into cells --> severe, potentially lethal electrolyte fluctuations

refeeding syndrome

Management of what disorder involves:

•Recognition of at-risk patients is important for prevention of sequelae

•Introduce the feeds slowly (Doig et al, 2015)

•10kcal/kg/day (NICE) which is about 37% of predicted energy requirements

•50% of predicted requirements (SCH)

•SCH recommend to increase in increments of 10% of total requirements, every 24 hours

•Ensure the replacement of thiamine, multivitamins and trace elements

•Proactively replace phosphate potassium and magnesium

refeeding syndrome

Prevention of what disorder involves:

• Recognition of at-risk patients is important for prevention of sequelae

• Introduce the feeds slowly (Doig et al, 2015) --> 10kcal/kg/day (NICE) which is about 37% of predicted energy requirements, 50% of predicted requirements (SCH), SCH recommend to increase in increments of 10% of total requirements, every 24 hours

• Ensure the replacement of thiamine, multivitamins and trace elements

• Proactively replace phosphate potassium and magnesium

refeeding syndrome

Monitoring of what disorder involves:

•Ensure careful monitoring of electrolytes during the first 2 weeks of refeeding

•Regular weight measurements

•Strict fluid balance chart