Download enteral nutrition case study - Dawn Ortiz, MS Dietetic Internship

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Name: Dawn Ortiz
Enteral Nutrition Support Case Study
23 yo male Pt admitted to ICU s/p motorcycle accident.
Dx CHI, Multiple fx, Glascow Coma Scale of 7. VDRF.
No significant PMH.
Pt is a weight lifter and plays football.
Ht. 6’3”, Wt. 230#
Labs: ALB 2.5, GLU 130, BUN 12, CREAT 0.8, Na 136, K 4.2
1. Determine the patient’s calorie, protein and fluid needs. Explain your answer
(show your work).
Based on the Glascow Coma Scale of 7, the patient’s needs are as follows:
Feeding weight: 105 kg
Energy needs: 3150-3675 kcal/day (30-35 kcal/kg)
Protein needs: 158-210 g/day (1.5-2 g/kg)
Fluid needs: 3150-3675 mL/day (30-35 mL/kg)
2. List the indications and contraindications for enteral nutrition support (give at
least 4 examples of each).
Indications for EN
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Malnourished patients expected to be unable to eat for greater than 5-7
days
Well-nourished patients expected to be unable to eat for greater than 7-9
days
Adaptive phase of short bowel syndrome
Following severe trauma or burns
Contraindications for EN
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

Patients expected to eat in less than 7-9 days (5-7 days if malnourished)
Severe acute pancreatitis
High output proximal fistula
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Inability to gain/maintain GI access
Intractable vomiting or diarrhea
GI obstruction
Severe peritonitis
Ileus, depending on the location and severity
3. List the access routes for enteral nutrition support.
Short term access (<6-8 weeks): Nasogastric tube (NG-tube), oralgastric tube (OG
tube), Nasoenteric tubes: Naso-duodenal tube (ND tube), Naso-jejunal tube (NJ
tube)
Long term access (>6-8 weeks): Percutaneous endoscopic gastrostomy (PEG),
jejunostomy tube (J-tube), Gastrojejunostomy tube (GJ tube), Percutaneous
endoscopic gastrojejunostomy (PEGJ).
4. What are the advantages of enteral vs. parenteral nutrition?
Throughout my dietetics education I have always been taught, if the gut works
use it! In comparison to PN, EN offers a safer and less expensive way to maintain
gut integrity. EN provides a feeding option that is closer to the natural
physiological metabolic process than PN. In EN food is still entering the digestive
tract at either the stomach or the intestines allowing for natural absorption of
nutrients. PN completely bypasses the digestive process, as nutrients are
absorbed directly into the blood stream.
5. Pt is to start on Enteral Nutrition Support. Choose formula from list below.
Justify your choice. Determine initiation, progression and goal rate of TF.
Your facility has six enteral nutrition products available.
Trauma/metabolic stressed patient needs a high calorie, high protein formula
with BCAAs (arginine, glutamine) and omega 3 fatty acids. Therefore, E is the
best option for this patient.
a.
b.
c.
d.
1.0kcal/mL, 40g Pro/L, 85% H2O, no fiber
1.0kcal/mL, 40g Pro/L, 84% H2O, 14g fiber
1.2kcal/mL, 54g Pro/L, 82% H2O, no fiber
1.5kcal/mL, 64g Pro/L, 76% H2O, 22g fiber
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e. 1.5kcal/mL, 94g Pro/L, 76% H2O, 7.5g fiber
Formula enhanced with Arginine (13g/L), Glutamine (7.6g/L),
Omega-3 FA (EPA 2.6g/L, DHA 1.1g/L)
f. 2.0kcal/mL, 80g Pro/L, 70% H2O, no fiber
Feeding weight: 105 kg
Energy needs: 3150-3675 kcal/day (30-35 kcal/kg)
Protein needs: 158-210 g/day (1.5-2 g/kg)
Fluid needs: 3150-3675 mL/day (30-35 mL/kg)
Initiation and progression: Start low and slow to avoid refeeding syndrome (it is
unclear how long it has been since the patient has eaten). I would start at 10
mL/hr and increase by 10 mL q 8 hours to make sure the patient is tolerating the
feeding based on lab values and GI responsiveness.
Goal rate: 90 mL/hr; provides 3240 kcal/day, 203 gm protein, 1642 mL/day
(additional fluid needs may be met by IV fluids)
6. What are possible causes of the following GI complications of TF? What can be
done to prevent these complications?
Nausea/vomiting: May be caused by feeding too much, too fast. Also giving a
formula that the patient cannot digest or feeding into a stomach that is not
working. To prevent: lower the rate, increase head elevation, change the
formula and the last option is to change route of feeding.
High residuals: May be caused by feeding at too high a rate or to part of the GI
tract that is not yet working. To prevent: lower the rate, increase head
elevation, recommend a pro-motility agent (reglan), change the formula and the
last option is to change route of feeding.
Abdominal distention: May be caused by feeding too much, too fast or using the
wrong formula. To prevent: Reduce the rate or feed intermittently versus
continuous. A pro-motility agent may also help move things along. Reducing
fiber and or fluid may also help with abdominal distension. Again changing the
feeding route is the last option for EN complications.
Diarrhea: May be caused by using a formula that is too low in fiber or feeding
too much, too fast. To prevent: check medications, add danactive right into tube
and provide soluble fiber (benefiber) or change formula. The last option would
be to change the feeding route.
Constipation: May be caused by using a formula that is too high or too low in
fiber, or feeding too slow. To prevent: Increase feeding rate, add/remove fiber,
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recommend a pro-motility agent or stool softener, also always make sure bowel
sounds are present before starting EN.
7. What problems are encountered when giving medications thru the feeding tube?
Before administering medications directly into the feeding tube, doctors should
make sure the bowel is working properly, otherwise diarrhea may result. Often
times the formula is blamed for diarrhea when it is actually being caused by the
medication. Medications given through feeding tubes may clog the tubes,
decreased drug efficacy and result in drug/formula incompatibilities.
8. What procedures are routinely used to prevent the occlusion of feeding tubes?
How can clogged tubes be safely reopened?
The most common procedure used to prevent the occlusion of feeding tubes is
to perform regular water flushes of the tube. This helps dislodge particles that
may get stuck in the tube. If water does not work, enzymes or mechanical
devices may be necessary to safely open the tube.
Two weeks later, the patient has a PEG placed in preparation for being transferred
to a rehab facility.
9. Is the current TF formula and rate still appropriate? If not, make new
recommendations, including a bolus feeding schedule.
Before placing the PEG, I would make sure speech therapy performs a swallow
evaluation test to find out if the patient may be advanced to a PO diet. If he fails
this test completely, and a PEG is a better entry option (likely to prevent
infection), I would recommend still using the same formula at the same goal
rate. However, if the patient is able to start a minimal PO diet, I would
recommend nocturnal bolus feeds based on how much food the patient is eating
during the day. I would perform a calorie count to determine the appropriate
rate to make sure the patient is meeting his energy needs. My goal would be to
gradually reduce the tube feeding rate to encourage PO intake.