Enteral Workshop – suggested answers
Group 1 –Case study #1
Convenor:
Equipment required:
1) 55 copies of case study #1
2) White board/ white board marker
3) Calculator/pen
Related Learning Outcome:
- be able to plan an appropriate enteral feeding regimen
- understand the management of NGT feeding regimen
- be able to calculate the nutritional requirements for
differing medical conditions
- understand the nutrition management of refeeding
syndrome
Case:
Alice is an 80-year-old female admitted from a nursing home
a right sided stroke. She has been assessed by the Speech
Pathologist as not appropriate for oral intake and to be NBM.
1) Where will you get details regarding her anthropometry?
Nursing home, family, estimate
You establish that her weight is 45kg, and her height is 5ft 4”
2) Calculate her estimated energy and protein requirements
(include all working out)
Height 163cm
Weight 45kg
BMI 16.9kg/m2 (underweight++)
IBW 58kg!
Comment on BMI, use of actual vs ideal body weight and when each might be
used.
Energy
Harris benedict: 2741 + 1800 + 1255 – 1568 = 4228kJ/1010kcal
X AF + IF= 1.4
= 1414kcal/day (31kcal/kg)
Schofield: 1.71 + 2.755 = 4.465MJ/1067kcal
X AF + IF = 1.4
= 1495kcal/day (33kcal/kg)
Protein:
1.0-1.2g/kg= 45-54g/day
3) Calculate an appropriate enteral feeding regimen
including starting regimen, water flush, and plan for
progression to goal rate.
NB: Consider intake hx, especially given weight ?refeeding risk
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Refeeding risk:
Depending upon recent diet hx, assuming no information commence
thiamine supplement prior to commencing enteral formula, baseline
EUC/CMP and supplement if required.
Once position of tube confirmed by medical officer and documented ok to
start: 20mL/hr 1kcal/mL with fibre formula x 24/24, 50mL water flush 4/24
plus IVT. Organise daily bloods for EUC/CMP.
Check bloods, if normal increase by ~250kcal per day (10mL/hr). If not,
keep formula at same rate and supplement where required.
Continue this daily until goal 55-60mL/hour x 24/24. If NUMF @ 55ml/hr =
1320ml, 1320kcal, 53g protein (1.2g/kg), 57mmol Na/50mmol K+, 20g fibre
or if NUMF @ 60mL/hr = 1440kcal/6025kJ (32kcal/kg) , 58g protein
(1.3g/kg), 62mmol Na/55mmol K+, 22g fibre.
If patient was definitely not at risk of refeeding:
Once position of tube confirmed by medical officer and documented ok to
start: commence 1kcal/mL fibre formula at 30-40mL/hr x 4/24, if tolerated
increase by 10mL ever 4/24 until goal rate reached (as above)
Suggest 50mL water flush 4/24 = 1680mL total fluid/1450mL free water
(32mL/kg), may need to slightly increase upon review.
4) Upon review:
i)
What are you checking?
Initial assessment/nutrition care plan remains appropriate, has clinical
condition changed etc.
ii)
What do you need to look at (include chart
names)?
Med chart, fluid balance chart, bowel chart, BGL chart (if
appropriate), biochem, weight (if done)
iii)
Who do you need to speak with?
Nurse, patient (if able)/family, doctor (if new issues)
Enteral Workshop
Group 2 –Case study #2
Convenor:
Equipment required:
1) 55 copies of case study #2
2) White board/ white board marker
3) Calculator/pen
4) 55 copies of enteral formula composition (either chart or
photocopy of company info for one company eg Nutricia)
Related Learning Outcome:
- be able to plan an appropriate enteral feeding regimen
- understand the management of NJT/PEJ feeding regimen
- be able to calculate the nutritional requirements for
differing medical conditions
- be able to describe the types of enteral nutrition formulae
and plan an appropriate feeding regimen
- have an appreciation of the issues with home enteral
feeding
Case:
1) List some clinical circumstances where postpyloric/jejunal enteral tube feeding may be required?
Recurrent aspiration, persistent reflux/vomiting, pancreatitis, persistent
large gastric aspirated in ICU despite prokinetics
2) What needs to be considered relating to the selection of
an enteral formula when commencing a postpyloric/jejunal feeding?
Osmolality: (a measure of the number of particles present in solution and
is independent of the size or weight of the particles) and compare with
plasma osmolality (normal osmolality in plasma is about 280 - 303 milliosmoles per kilogram)
Volume: emphasis location of delivery
Delivery method: commence with continuous feeding, may be able to
grade over to bolus with time.
Lucy is a 74-year-old female who is admitted with recurrent
aspiration pneumonia due to Parkinson’s disease. She has a
PEG and has been established on enteral tube feeding for
approximately 12 months. The PEG is now going to have a
jejunal extension due to the recurrent aspiration. Lucy
usually mobilises with a stick and lives with her daughter and
her family.
Her weight is 54kg and height is 153cm.
3) Calculate her estimated energy and protein requirements
(include all working out)
Check previous enteral feeding regimen and weight hx (ie if stable potentially
aim for same).
BMI = 23.1kg/m2
Harris Benedict: 2738 + 40W + 7.5H – 20A
= 2738 + 2160 + 1148 – 1480
= 4566kJ (1100kCal)
X AF (1.3-1.4) + IF (1.1) = 1.4-1.5
= 6392-6849kJ (1540-1650kCal)
Schofield: 38W + 2755
= 4807kJ (1145kCal)
X AF + IF = 1.4-1.5
= 6730-7211kJ (1603-1718kCal)
Protein: 59.4g (1.1g/kg)
Fluid: 1603-1718ml (1ml/kCal) OR 1620ml (30ml/kg)
4) Calculate an appropriate enteral feeding regimen
including starting regimen, water flush, and plan for
progression to goal rate.
Assume no refeeding risk:
- Follow post-jejunal extension insertion instructions from gastroenterologist
- Commence 1kcal/mL with fibre formula at 30mL/hr x 4/24, increase by
10mL/hr every 4/24 until goal rate 70mL/hr (may need to be slower). Water
flush 50mL 4/24.
- Discuss goal rate and potential issues re high volume, PEJ will not
necessarily prevent aspiration pneumonia etc.
- Need to discuss with medical team, and consider local protocol re feeding
overnight.
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Consider options re 1.5kcal/ml, 2.0kcal.ml formula but balance with
osmolality.
? Nutrison Concentrated (470mOsm/kg H20) then goal only 35ml/hour x
24/24 or if 16/24 feeds 50-55mL/hr
- Given this is Lucy’s sole source of nutrition long-term, particularly need to
check against RDI and supplement micronutrient where required.
5) What will you need to do in order to organise Lucy for
discharge?
Check discharge destination, has the feeding regimen changed from prior
to admission, organise education if required, contact daughter to advise of
feeding regimen, organise follow-up (outpatient clinic or if for placement
recommend NH organises dietitian consultation)
Enteral Workshop
Group 3 – Practical Aspects of Enteral feeding
Convenor:
Equipment required:
1) Enteral company names (Company Names Enteral &
Parenteral doc in 2008 folder)
2) Enteral formula from each of four enteral companies to
display (basic products eg 1kcal, 1.5kcal, 2.0kcal/mL with
and without fibre, not specialised formula)
3) 5 x feeding pumps plus sets to fit formula (from Tyco)
4) Enteral formula for students ‘hands-on’ with pumps (5 x a
ready-to-hang formula from each company)
Related Learning Outcome:
- be able to describe the types of enteral nutrition formulae
- understand the management of feeding regimens
Practical:
- Enteral feeding company displays of enteral nutrition
formulae (on table, set-up). Brief explanation re 4
companies and basic formula types/names.
- Convenor to demonstrate set-up of enteral feeding pump
(including formula, giving-set, priming line, setting rate)
- Students to be in groups of 2-3 (total 5 pumps) for ‘handson’ experience of setting up enteral feeding pump
Enteral Workshop
Group 4 – Considerations and practical aspects of Home
Enteral Nutrition tube feeding
Related Learning Outcome:
- have an appreciation of the issues with home enteral
feeding
See workshop 4 document handout.