Gi #10: Enteral And Parenteral Nutrition

Front 1

Why is it important to maintain nutrition when someone is sick?

Back 1

- decrease the metabolic response to stress
- prevent oxidative injury
- preserve gut barrier
- modulate immune response
- diminish complications, encourage healing

Front 2

When do you use enteral nutrition?

Back 2

- When oral intake is inadequate or contraindicated ("If the gut works, use it")

Ex: dysphagia, malnutrition, cognitive impairment, coma, head/neck tumor, pancreatitis

Front 3

A patient with pancreatitis and an APACHE II score of >10 should receive what type of nutritional support?

Back 3

APACHE II (prognostic score) >10 = severe, Enteral/Parenteral nutrition

(if <9, then provide supportive therapy, IV fluids, because patient has increased likelihood of eating)

Front 4

What are contraindications to enteral nutrition?

How do you prevent aspiration when giving enteral nutrition?

Back 4

Absolute contraindications = small bowel obstruction, ileus, short bowel syndrome, fistula, ischemia, severe pancreatitis with relapsing pain. Also consider if GI bleed, N/V/D

Raise head of bed (HOB) to >30 degrees to prevent aspiration

Front 5

Advantage of a G-J tube (combined gastrostomy/jejunostomy)?

What is the most common metabolic complication of enteral nutrition?

Back 5

You can suck the stomach dry and feed jejunum at same time (great for patients with gastroparesis, delayed emptying, or vomiting)

Most common = Hyperglycemia (other complications = access, psychological, aspiration, GI reflux, dumping syndrome)

Front 6

How do you check a gastric residual?

What would you do if a gastric residual is >250ml?

Back 6

Aspirate or suction out fluid from stomach. If delayed gastric emptying (tumor, occlusion, etc.) and fluid residual gets high, you might predispose to more aspiration.

If gastric residual gets >250, hold food.

Front 7

Why does one get diarrhea with enteral nutrition?

Back 7

Mainly because of rapid infusion rate, lack of dietary fiber, many medications (sorbitol containing) that are hyperosmolar and can cause diarrhea.

Front 8

What are the indications for Parenteral Nutrition?

Back 8

GI dysfunction (bowel obstruction, short bowel syndrome (anatomic or functional), inflammatory bowel disease, bowel ischemia, severe pancreatitis, anything that predisposes to malabsorption).

Front 9

What are some mechanisms of malabsorption in short bowel syndrome?

Back 9

Acid hypersecretion, rapid intestinal transit, bacterial overgrowth, impaired residual bowel function. Patients can have diarrhea (decreased absorption of liquid).

Front 10

At what length of small bowel would we consider placing a person on parenteral nutrition?

What is the ideal situation in which to use PICC (peripherally inserted central catheter)?

Back 10

>180cm = minimal, <60cm= permanent PN

PICC- antecubital approach, good for short term. No risk of pneumothorax. Appropriate for home care.

Front 11

What are the 2 major complications that patients on PN support die of?

Which type of catheter is associated with the greatest risk?

Back 11

2 major complications = infection & liver failure

Triple lumen catheter (short term, used in-patient only), multiple lumens increase chance of infection. Placed in subclavian - risk of pneumo.

Front 12

What is the difference between a Hickman catheter and Port-a-cath?

Back 12

Hickman = catheter tunneled into neck (gives continuous IV infusion therapy), appropriate for home care.

Port-a-cath= completely under skin, patient self injects therapy. Can be done overnight leaving pt functional during day.

*both are long-term uses (months to years)

Front 13

Why do patients on PN develop liver failure? If a patient develops severe complications, what is their only treatment option?

Back 13

-lack of use of gut
- IV fat emulsion is mainly omega 6 (immunosuppresive)
- over-feeding
- frequent infection/treatment
--> leads to chronic cholestasis

Small intestinal transplant for pts who develop severe complications (but risks associated with lifelong immunosuppression)

Front 14

What is refeeding syndrome a complication of?

Back 14

Pts with anorexia, chronic malnutrition, or prolonged fasting who are refed, especially on PN.

Phosphate, Mg, and K stores get rapidly used up as the body readjusts to increased fat and protein synthesis.

Patients become hypokalemic, hypophosphatemic, hypomagnesemic, they can show edema.

Front 15

Who is a candidate for bariatric surgery?

Back 15

BMI >35 + complications (DM, cardiomyopathy, sleep apnea, etc.) , or BMI >40

*pts must also be emotionally healthy, absent of drug or alcohol intake, and undergo screening, exercise.

Front 16

What type of bariatric procedure leaves the patient with a very small intestine (possibly lead to malnutrition complications)?

What type of bariatric procedure can be overcome by drinking calorically dense foods?

Back 16

Biliopancreatic diversion (divert bile and pancreatic enzymes), also roux-en-Y (bypasses stomach), is malabsorptive.

Adjustable lap band can be done laparoscopically but can be outsmarted.

Front 17

What is the main reason for weight loss failure after gastric bypass?

What is the most important nutrient that patients who have this surgery need to get?

Back 17

Dietary non-compliance or lack of behavioral changes (exercise).

Lots of protein! high protein, low fat, low sugar diets. They are at risk for protein deficiencies and also some vitamins and minerals (iron, vit D, Ca2+, B12).