1. Functioning GIT
2. Length of Feeding
3. Presence of Risk ofAspiration
Considerations in TF (3)
True
True or False: EN is preferred over PN because it is safer, economical, and maintains gut structure and integrity
1. Complete intestinal/colonic obstruction
2. Intractable vomiting
3. Active GIT bleeding and shock
Contraindications of enteral feeding (3)
1. PEM with inadeq oral intake previous 5 days OR normal NS but with inadeq oral intake previous 7-10 days
2. CNS disorders: coma, CVA, Parkinson's
3. GIT diseases: Chron's, gastroparesis, short bowel syndrome, chronic pancreatitis
4. Psych disorders: severe depression, anorexia nervosa
Indications for enteral feeding (4)
Polymeric Formula
Composed of CPF in high molecular wt form and therefore lower osmolality; require normal digestive and lipolytic activity
Elemental formula
Low residue and use free AAs or peptides as a protein source; oligosacch or monosacch provide the CHO source nd most contain medium/long chain trigylcerides
Modular Formula
Not nutritionally complete because they contain single nutrients: C/P/F. Can be added to std enteral prod
Specialty Formula
Available for use in px with a variety of clinical conditions including renal, respiratory, hepatic, insuff, DM, immunocompromised, and fat or CHO malasbsorption
1. Immunocompromised px
2. For infusion through tubes smaller than 10 French
3. For continuous feeding (unless formula hangs for ≤ 2rs
4 if fluid restriction of < 900 mL/day is required
5. In cases of multiple food allergies
6. If a jejunostomy tube is used
BTF contraindications (6)
1 mL/kcal
Recommended daily water requirement in the absence of hepatic, renal, or cardiac disease
Isotonic
The ideal formula is ______
1 kcal per 1 mL
ideal nutrient density for adults
2/3 kcal per 1 mL
ideal nutrient density for infants
at least 25% of the total formula vol which can be adminstered in 2-3 separate doses
How much additional free water should patients without fluid restriction should receive?
30-45˚
Degree of elevation of px' head and neck for 1 hr after feeding to prevent aspiration
At least 3x weekly
Weighing and recording of the px wt should be done at least ____
Bolus Feeding
Rapid delivery by syringe of 240-400 mL o formula every 4-6 hrs; simulates normal food intake in terms of gallbladder motility
Timed Intermittent
Provision of 100-400 mL of enteral formula with an interval of 2-4 hrs; can be used if there is no hx of malabsorption
Continuous Drip
Requires infusion of the formula using a pump or gravity drip over a period of 16-24 hrs
Cyclic Administration
Infuses the formula for 8-16 hrs, usu overnight, using an infusion pump
IV (intravenous)
called Total Parenteral Nutrition (TPN)
TPN
Given when the condition is expected to continue on a minimum of 7 days
1. Intractable vomiting (acute pancreatitis)
2. Severe diarrhea of > 500 mL/day stool, or malabsorption
3. Several trauma/ major abdominal surgery, when EN including jejunostomy cannot be used for at least 7 days
4. Small bowel or colon obstruction
Indications of TPN (4)
1. Hemodynamically unstable px
2. Px with severe pulmonary edema or fluid overload
3. Px with anuria w/o dialysis
4. Px with profound metabolic or electrolyte disturbances
Contraindication of TPN
~2-3 L/day and should not exceed 4 L
Fluid intake of PN solutions
3.4 kcal/g
E yield of dextrose (glucose monohydrate)
Soybean or safflower oil
Lipid emulsions of PN solutions come in 10% or 20% of _______ which may be available in 100, 200, 250 and 500 mL bottles
Serum electrolyte concentration
Parenteral electrolyte content must be adjusted according to
Vit K (contraindication for heparin)
Multivitamins except ______ are provided in concentrated PN formulations based on std recommendations
Insulin and heparin (anticoagulant)
Additives such as ______ are used only when necessary
Simple IV Infusion
Delivered through a peripheral IV catheter inserted into a small diameter peripheral vein
PPN (peripheral parenteral nutrition)
Used for px with mild nutri deficiencies; uses the small diameter veins that carry blood from the arms and legs; lipid emulsions are commonly used to provide short term nutrition (11-2 wks)
CPN (central parenteral nutrition)
Infusion of concentrated solutions delivered through the central veins for longer period period
Pneumothorax
presence of air in the pleural cavity/chest
Air embolism
Presence of air in the tube or in the blood vessel that obstructs the parenteral flow
Sepsis
Presence of the disease-causing micorogranisms of the blood
Hemothorax
presence of blood in the chest cavity
EFA Deficiency Symptoms
Failure to grow, dermal problems, poor immune fxn
Metabolic imbalance
Characterized by an increase or a decrease of nutrients in the blood
Refeeding Syndrome
Precipitates when there is aggressive administration of nutrition particularly via IV route
Hypocaloric high protein nutrition
Safest, most physiologically rational feeding for px whose body fat store is adeq BMI>18
Existing low muscle mass and/or major protein catabolism
Highest prio px
1.2 kg/kg ABW or 2 - 2.5g/kg IBW with adjustment of goal protein intake by the results of N-balance studies
High protein feeding may be started with ______
50-70% of estimated E-needs or <14 kcal/kg ABW
Hypocaloric feeding be started with ______
2 - 2.5g/kg/day
Critically ill px should receive ______ protein
Gastrostomy and Jejunostomy
Long Term EN (>6-8 wks)
nasogastric, nasoduodenal, nasojejunal (NGT and NJT <6-8 wks)
tube feeding less than 4 weeks (Short Term EN)
CPN
Long Term PN
PPN
short term therapy, usually post-surgery (when enteral is resumed in 5-7 days) mild/moderate malnutrition, or as a supplement to enteral
0.33 mm
1 french =
8-12 Fr
Size of tube for NGT and Naseoenteric
18 - 28 Fr
Size of tube for gastrostomy
Avoid
For pedia cases, ______ big syringe bec of risk of aspiration
Bolus Feeding
Most likely to generate high residual volumes
True
True or False: In critically ill adult and children, continuous feeding has been reported superior to gravity feeding in terms of less diarrhea, and more wt gain due to improved absorption
Gastric residuals
the volume of formula and GI secretions remaining in the stomach after a previous feeding
Not to exceed 50% of the amount infused
Volume of gastric residuals
False: Often, diarrhea is not caused by EN, and while investigating the cause, nutrition support should not be withheld
True or false: nutrition support should be withheld while investigating the cause of diarrhea
FEES - Functional Endoscopic Evaluation of Swallowing
Test for px with difficulty of swallowing ; to test their swallowing ability, foods with green dye are given. Sample foods: pureed food, thick liquid, thin liquid, crackers, ice chips
Pureed
Dysphagia Level 1
Minced
Dysphagia Level 2
Ground and Chopped
Dysphagia Level 3
25%
To prevent refeeding syndrome, start nutri support at _____; advance requirements slowly over 3-5 or 5-7 days until goals are reached