Feeding

Question 1

How to confirm correctly placed NG tube?

Q3: Methods which should be NOT be used for confirming NG tube position include

Q: if the PH is 5.5 in aspirate, what your action. ?

Q: normal PH of the stomach ?

Answer 1

According to NICE guidelines (CG32)
• Measuring the PH of aspirate using PH indicator strips/paper
Radiography (chest x-ray)

• Auscultation of air insufflated through the feeding tube (‘whoosh’ test)
• Testing the acidity/alkalinity of aspirate using blue litmus paper
• Interpreting the absence of respiratory distress as an indicator of correct positioning
• Monitoring bubbling at the end of the tube
• Observing the appearance of NG tube aspirate

I will pull the tube out (mostly not in the stomach)
Between 1.5 — 2

Question 2

Feeding options? Methods of feeding?

Types of enteral (non-parenteral) feeding?
Advantages and disadvantages of naso-jejunal tube?

Complications of enteral feeding?

Complications of parenteral feeding?

What is refeeding syndrome and cause behind it?

Answer 2

• Parenteral e.g. TPN, PPN
Enteral e.g. NG, NJ, surgical jujenostomy.

• Oral • Nasogastric • Naso duodenal • Naso jejunal
• Percutaneous endoscopic gastrostomy (PEG)
• Jejunostomy

Advantages
• Bypass the Stomach o less liability to pneumonia o Avoids gastric phase of stimulation o Doesn’t stimulate pancreatic secretions o Feed delivered directly to the intestine thus maintaining mucosal integrity

Disadvantages
• Needs endoscopic guidance for placement
• Smaller in diameter (more prone to kinking)

Tube related:
• Kinking • Misplacement • Injury • Migration • Blockage • Infection (sinusitis) • Aspiration pneumonia

Feed related:
• Diarrhea • Nausea • Vomiting • Aspiration • Refeeding syndrome • Fluid & electrolyte imbalance
• Deranged liver functions

Line related:
• Infection; sepsis, thrombophlebitis • Thrombosis • Pneumothorax • Hemothorax

Feed related:
• Fluid overload, overfeeding
• Electrolyte imbalance, Hyperchloremic metabolic acidosis (if there is an excess of chloride)
• Hyperlipidemia
• Hyperammoniemia, e.g. if there is liver disease, or a deficiency of L-glutamine and arginine
• Essential fatty acid deficiency
• Hypo and hyperglycemia
• Ventilatory problems due to excess production of CO 2 if too much glucose is used in the mixture. In the ventilated critically ill patient, the amount of glucose given in 24 hours may have to be restricted to 5g/kg
• The most potent risk is that of the re-feeding syndrome, particularly in the chronically malnourished.
• Gut atrophy: due to the absence of trophic signals released in response to luminal nutrients, during regular feeding which will lead to bacterial translocation

It is a metabolic disturbance which occur on feeding a person following a period of starvation. The metabolic consequences include:

• Hypophosphataemia

• Hypokalaemia

• Hypomagnesaemia

• Abnormal fluid balance

Question 3

Patients at high risk for refeeding syndrome?

How to prevent refeeding syndrome?

Signs of malnutrition?

Answer 3

High Risk if ONE or more of the following:
• BMI < 16 kg/m²
• Unintentional weight loss >15% in the last 3–6 months
• Little or no nutritional intake >10 days
• Low baseline levels of potassium, phosphate, or magnesium

⸻

Or if TWO or more of the following:
• BMI < 18.5 kg/m²
• Unintentional weight loss >10% in the last 3–6 months
• Little or no nutritional intake >5 days
• History of:
• Alcohol abuse
• Drugs such as insulin, chemotherapy, diuretics, or antacids

• Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days
• Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements
• Give K + (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)

Patients identified as being malnourished
• BMI < 18.5 kg/m2
• Unintentional weight loss of > 10% over 3-6/12
• BMI < 20 kg/m 2 and unintentional weight loss of > 5% over 3-6/12

AT RISK of malnutrition
• Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
• Poor absorptive capacity
• High nutrient losses
• High metabolism

Question 4

Indications of TPN:

Routes of TPN administration?

Types of electrolytes in TPN?

Components? / TPN ratio of CHO, protein & fat?

How it is given?

Q7: Other than glucose, what other TPN constituents provide energy?

Answer 4

General critical illness:
• Severe malnutrition (> 10 % weight loss)
• Multiple trauma
• Sepsis with MOF
• Severe burns

Gut problems:
• Short bowel syndrome (short gut)
• Enterocutaneous fistula
• Bowel obstruction
• IBD
• Radiation enteritis

Central line or PICC

• Sodium chloride
• Calcium chloride
• Potassium chloride
• Magnesium chloride

Water, carbohydrates (50%), lipids (30%), proteins, vitamins, nitrogen, trace elements

• In a central line because of high osmolarity (must be < 900 mOsm/L)

• Fat, provide 50% of energy.

Question 5

what happens to the bowl of people who are not enteraly feeded? and why?

If patient has mucosal atrophy what will be the result?

Nutrition monitoring

Answer 5

• Mucosal atrophy: when food is going through the bowl it stimulates the release
  hormones that maintain the mucosal integrity. And the lack of glutamine from
  enteral feeding cause mucosal atrophy also.

Patient will loss cellular adhesion and there will be translocation of bacteria

Daily:
- General condition.
- Weight (if fluid balance concerns)
- Electrolytes balance (until levels stable)
- Fluid balance,
- Glucose tolerance.

Biochemistry:
- Daily: Na, K, urea & creatinine
- Ca & Mg»_space; twice a week
- Trace elements (zinc ,copper)»_space; monthly
- Vit B12 , folate , vit A»_space; monthly
- BMI :
At start then monthly

Question 6

From which sources may the energy requirements be satisfied? How much energy does each of these provide?

What are the disadvantages of using glucose as the main energy source?

Answer 6

The predominant sources of energy are from carbohydrates and lipid, but protein catabolism also yields energy

• Fats provide 9.3 kcal/g of energy
• Glucose provides 4.1 kcal/g of energy
• Protein provides 4.1 kcal/g of energy

The problems of glucose are

• Glucose intolerance: as part of the stress response, critically unwell patients are often in a state of hyperglycemia and glucose intolerance. Therefore, if glucose is the only source of energy, patients will not receive their required daily amount due to poor utilization of their energy source

• Fatty liver: the excess glucose occurring as a consequence of the above is converted to lipid in the liver, leading to fatty change. This may derange the liver function tests

• Respiratory failure: the extra CO 2 released upon oxidation of the glucose may lead to respiratory failure and increased ventilatory requirements

• Relying solely on glucose may lead to a deficiency of the essential fatty acids. Therefore, ∼ 50% of the total energy requirement must be provided by fat.