Chapter 13: Complications of Enteral Nutrition

What is the minimum urine output required to remove waste? A. 30 ml/hr or ~700 ml/day B. 50 ml/hr or ~1000 ml/day C. 60 ml/hr or ~1500 ml/day

A. 30 ml/hr or ~700 ml/day Urine output range for adults is typically 0.5-2 ml/kg/hr. Output of at least 1 ml/kg/hr is useful guideline for adequate urine output.

What are the signs and symptoms of nonocclusive bowel necrosis? When do they usually occur? A. Abdominal distention, nausea, vomiting; day 6 after EN initiation B. Abdominal distention, nausea, vomiting; day 2 after EN initiation C. Abdominal pain, nausea, vomiting; day 6 after EN initiation D. Abdominal pain, nausea, vomiting; day 2 after EN initiation

A. Abdominal distention, nausea, vomiting; day 6 after EN initiation. Typical signs of feeding intolerance (abdominal distention, nausea, vomiting) are common with NOBN. Symptoms are nonspecific and may be observed in enterally fed patients in ICU without NOBN NOBN may present later in the patient's clinical course rather than shortly after enteral feeding initiation Mean day of diagnosis after EN initiation was Day 6 with a range of day 4 to day 18.

What remains the appropriate screening method for ileus or obstruction? A. Plain x-ray B. Upper gastrointestinal series C. Small bowel follow through D. Hydrogen breath test

A. Plain x-ray Plain radiology remains the appropriate screening method if ileus or obstruction are suspected. Simple method of assessing distention is to inject a small amount of contrast material through the feeding tube and observe intestinal anatomy and motility on a follow-up, single x-ray or under fluoroscopy. Technique can often provide a clear picture of the clinical situation. Particularly useful when the position of the feeding tube is in question.

Which of the followings is correct when preparing enteral formula for administration? A. Preparation and administration of EN formula involve a trained personnel using good handwashing, clean gloves, aseptic technique in a clean environment B. Use a blender to add modular products to EN formula allows even mixing and prevents lump-forming for administration C. Lids of cans should be cleansed under running water and dry before decanting the formula D. Add new formula to the remaining formula left in the current feeding bag to avoid interruption of a feeding

A. Preparation and administration of EN formula involve a trained personnel using good handwashing, clean gloves, aseptic technique in a clean environment Use of a blender to add carbohydrate and protein modular additives to formula carries a high risk for contamination during the mixing process and should be avoided Lids of cans should be cleansed with isopropyl alcohol allowed to dry before pouring the formula into the delivery receptacle. Formula should not be added until the previous formula has infused. Feeding bag should be changed every 24 hours.

Any drug in a liquid vehicle given via a small bowel feeding tube should be diluted to avoid a hypertonic-induced, dumping-like syndrome. A. True B. False

A. True Any drug in a liquid vehicle given via a small bowel feeding tube should be diluted to avoid a hypertonic-induced, dumping-like syndrome.

It may be advisable to follow different protocols for GRVs with gastrostomy tubes as opposed to nasal tubes? A. True B. False

A. True Gastrostomy tubes are positioned in the anterior abdomen and are unlikely to allow full withdrawal of stomach contents during GRV checks GRV of 100 mL or greater with a gastrostomy tube has been suggested as a prudent trigger for careful evaluation of the patient for GI symptoms.

EN maybe continued despite abdominal distention if intestinal appearance and functions are normal. A. True B. False

A. True If intestinal appearance and function are normal, EN may be continued despite distention. Feedings may need to be discontinued, however, if motility is poor, the bowel is markedly dilated, or the patient's discomfort too severe

Raising the HOB 30 to 45 degrees during gastric feeding can lower the incidence of aspiration pneumonia. A. True B. False

A. True Raising the HOB 30 to 45 degrees during gastric feedings has been associated with decreased esophageal and pharyngeal reflux of gastric contents and lowered incidence of aspiration pneumonia

Severely cachectic patient with renal failure with a creatinine level significantly lower than 1 mg/dL a BUN level greater than 100 mg/dL and a BUN:Creatinine ratio greater than 100:1 might still be adequately hydrated. A. True B. False

A. True Severely cachectic patient with renal failure with a creatinine level significantly lower than 1 mg/dL a BUN level greater than 100 mg/dL and a BUN:Creatinine ratio greater than 100:1 might still be adequately hydrated.

Patients with dysphagia may aspirate saliva and develop aspiration pneumonia independent of the presence of gastric contents. It is difficult to relate tube feeding as a cause for aspiration pneumonia. A. True B. False

A. True Patients with dysphagia may aspirate saliva and develop aspiration pneumonia independent of the presence of gastric contents. No reliable method to detect pulmonary aspiration of tube feeding formula is currently available. Radiographic findings are generally nonspecific and insensitive.

Should all malnourished patients be suspected for refeeding syndrome? A. Yes B. No

A. Yes Potential for the serious electrolyte deficiencies associated with refeeding syndrome should be anticipated in all malnourished patients, especially those with large electrolyte losses Increased risk 1. Diarrhea 2. High output fistulas 3. Vomiting

How frequently should tube fed patients be assessed for intolerance? A. every 4 hours B. every 6 hours C. every 8 hours D. every 12 hours

A. every 4 hours Tube fed patients should be assessed for signs of tube feeding intolerance at 4 hour intervals.

What is absorption of glucose from continuous feeds most impacted by? A. glucose infusion rate B. glycemic index

A. glucose infusion rate Absorption of glucose from continuous feeds is more affected by the rate of carbohydrate delivery than the glycemic index.

How can weight change be related to fluid loss numerically? A. 0.5 kg of weight change = 1 L of fluid B. 1 kg of weight change = 1 L of fluid C. 2 kg of weight change = 1 L of fluid D. None of the above is correct

B. 1 kg of weight change = 1 L of fluid Clinicians can assume that 1 kg of weight change equals 1 L of fluid.

Which of the following actions is most appropriate for enhancing gastric emptying during the administration of EN? A. Keep the bed in Trendelenburg position B. Decrease the rate of a continuous feeding infusion, or change from bolus to continuous feeding C. Switch to an enteral formulation with a higher fat content D. Switch to an enteral formulation with a higher protein content

B. Decrease the rate of a continuous feeding infusion, or change from bolus to continuous feeding Factors that delay gastric emptying 1. large boluses of fluid given at one time 2. increased rate of formula infusion 3. increased fat content of the solution 4. Infusion of solution colder than room temp Elevation of HOB and turning of the patient slightly to the right side allows gravity to help drain the stomach, such positions are often difficult to achieve in the hospital environment

Checking GRV is one way to assess EN tolerance. A low GRV indicates intact digestion and absorption and is associated with reduced ventilator-associated pneumonia in critically ill patients. A. True B. False

B. False Elevated GRV alone does not correlate with intolerance. In a prospective randomized trial, checking GRVs did not decrease the incidence of VAP in critically ill patients. SCCM ASPEN do not recommend routine checks of GRVs in critically ill patients. If ICUs still use GRVs SCCM/ASPEN further recommend that clinicians avoid holding EN for GRVs less than 500 mL in the absence of other signs of feeding intolerance. If GRVs are low but nausea persists, patients may benefit from antiemetic medications.

Powdered formulas are sterile and therefore, they can be prepared with either tap or sterile water. A. True B. False

B. False Formulas provided in liquid form undergo heat sterilization, whereas powdered formulas are not required to be sterile and may contain contaminants To minimize the risk for contamination powdered formulas should ideally be reconstituted with sterile water.

Hyperosmolar EN formulas frequently cause diarrhea and therefore, diluting a high osmolality EN formula is recommended. A. True B. False

B. False Hyperosmolar EN products rarely cause clinically significant diarrhea unless they are infused at a very high rate or administered by bolus into the small bowel. Diluting the formula with water may result in suboptimal nutrient provision. Formula dilution has not been shown to improve tolerance. This practice is discouraged because it contaminates formula If a clinician suspects that the hyperosmolality of an EN formula is causing diarrhea, changing to an isotonic formula may be beneficial.

Incidence C.difficile infection and C.difficile associated diarrhea were significantly higher in tube-fed patients compared with non-tube fed patients. Probiotics are recommended as a prophylactic treatment on all tube-fed patients. A. True B. False

B. False Incidence C.difficile infection and C.difficile associated diarrhea were significantly higher in tube-fed patients compared with non-tube fed patients. Risk was greatest for those receiving postpyloric tube feeding. Recommended testing for C. difficile while investigating other etiologies for diarrhea in tube-fed patients. Probiotics are not recommended as a prophylactic treatment.

If the infusion rate or volume of bolus was decreased initially due to delayed gastric emptying, it should never be advanced again and supplemental PN should be considered. A. True B. False

B. False Once tolerance is achieved the rate or volume will typically be gradually increased every 6 to 24 hours until nutrition goals are met. If nausea or vomiting occurs as the rate of administration or bolus volume of the EN increases, the rate or volume should be reduced to the greatest tolerated amount, attempt to increase the rate again after symptoms abate. If these efforts fail small bowel access should be considered.

To prevent hypokalemia in TF patients, it is important to supplement potassium to above normal before initiation of tube feeding and monitor serum potassium daily until stable with patient at goal TF rate. A. True B. False

B. False Preventative measures/treatment for hypokalemia in TF patients include: 1. Supplement potassium to normal before initiation of tube feeding 2. Monitor serum potassium daily until stable with patient at goal TF rate 3. Supplement potassium and chloride 4. Consider supplementation protocol

Use of predigested enteral products when malabsorption is suspected, strong data support their use to prevent intolerance or overcome malabsorption/maldigestion during enteral feeding. A. True B. False

B. False Use of predigested enteral products when malabsorption is suspected, only weak data support their use to prevent intolerance or overcome malabsorption/maldigestion during enteral feeding.

Which one is not a consequence of refeeding syndrome? A. Arrhythmias B. Hypoglycemia C. Cardiac failure D. Aspiration

B. Hypoglycemia 5 Consequences of refeeding syndrome: 1. Arrhythmias 2. Respiratory failure 3. Cardiac failure 4. Aspiration 5. Death

How should most drugs and electrolytes be prepared for enteral administration? A. Give IV forms and administer through an enteral access B. Mix with a minimum of 30 to 60 mL of water and administer through an enteral access C. Mix with a minimum of 30 to 60 mL of normal saline and administer through an enteral access D. Mix with a minimum of 30 to 60 mL of D5W and administer through an enteral access

B. Mix with a minimum of 30 to 60 mL of water and administer through an enteral access Most drugs and electrolytes (potassium) should be mixed with a minimum of 30 to 60 mL of water per 10 mEq dose to avoid direct irritation of the gut.

Does the presence of edema preclude dehydration? A. Yes B. No

B. No Presence of edema indicating total body fluid and salt overload does not guarantee intravascular volume adequacy. Aggressive diuresis of an acutely ill patient may lead to low vascular volume.

Do the critical care guidelines recommend fiber in tube-fed patients who are hemodynamically unstable? A. Yes B. No

B. No SCCM/ASPEN guidelines recommended that fiber be avoided in patients who are not hemodynamically stable. Risk factors are not well understood

Which of the followings would likely be the cause of nausea in EN patients? A. Allergy to enteral formula ingredients B. Obstipation C. Reclined position during TF infusion D. High osmolarity of the TF formula

B. Obstipation Clinicians should monitor stool frequency in patients who complain of nausea. Obstipation or fecal impaction may lead to distention and nausea.

What are the ASPEN recommendations for starting enteral nutrition in patients at risk for refeeding syndrome? A. Provide only 10% of energy goal on Day 1, advance TF towards goal over 7-10 days. B. Provide 25% of energy goal on Day 1, advance TF towards goal over 3-5 days. C. Provide 50% of energy goal on Day 1, advance TF towards goal over 1-2 days. D. None of the above.

B. Provide 25% of energy goal on Day 1, advance TF towards goal over 3-5 days. ASPEN recommends that EN for patients at risk for refeeding syndrome should provide only 25% of the energy goal on Day 1. Attention to the energy contribution from IVF. Cautiously advanced toward the energy goal over the next 3 to 5 days as dictated by clinical status and/or stable electrolyte levels.

What is one of the most feared complications of EN support? Why? A. Elevated blood glucose B. Pulmonary aspiration of tube feeding formula C. Diarrhea D. Clogged feeding tube

B. Pulmonary aspiration Pulmonary aspiration of tube feeding formula is one of the most feared complications of EN support because it can lead to acute pulmonary pathology.

What should be done to prevent dehydration if a tube fed patient misses a feeding? A. Do nothing. B. Replace the fluid content of that feeding. C. Give double of the TF amount at the next feeding. D. Start TPN.

B. Replace the fluid content of that feeding. Patient misses a feeding then the fluid content of that feeding should be replaced

Which of the following is the most appropriate initial action for the management of tube feeding-associated diarrhea? A. Change to an enteral formulation with fiber B. Review the patient's medication administration record to determine whether hyperosmolar agents are being administered C. Change to a peptide based enteral formulation D. Use an antimotility agent

B. Review the patients medication administration record to determine whether hyperosmolar agents are being administered Clinically significant diarrhea develops during EN, the most appropriate initial action is to evaluate whether hyperosmolar medications that could result in liquid stooling are being administered. If none are in use, testing for the presence of Clostridium difficile; if those results are negative, the addition of fiber from a formulation that contains fiber or supplemental fiber may be beneficial. Adding an antimotility agent or changing to a peptide-based formula should be considered if diarrhea continues despite these initial interventions. PN should be initiated only if the other treatment modalities fail.

Which of the following would not reduce aspiration risk? A. Good oral care B. Trendelenburg position C. Small bowel feeding D. Continuous tube feeding schedules

B. Trendelenburg position Measures to reduce aspiration risk: 1. HOB elevation at least 30 to 45 degrees or positioning patient upright in a chair If such position is contraindicated consider the reverse Trendelenburg position 2. Good oral care twice daily Chlorhexidine in critically ill patients 3. Continuous tube feeding schedules 4. Minimal sedation techniques 5. Appropriate and timely oropharyngeal suctioning (prior to lowering HOB, deflating the cuff of endotracheal tubes or extubation) 6. Prokinetic agents 7. small bowel feeding

Practice of tinting enteral formulas should be abandoned. A. True B. False

B. True Public Health Advisory issued by the US FDA on 9/29/2003 reported blue discoloration of body parts and fluids followed by refractory hypotension, metabolic acidosis and death in patients receiving tube feedings containing Food Drug and Cosmetic Blue No 1 dye. Practice of tinting enteral formulas should be abandoned.

At what level should GRVs be re-instilled? A. 100 ml B. 150 ml C. 250 ml D. 500 ml

C. 250 ml Unless the patient is vomiting, GRVs up to 250 mL should be re-instilled to replace fluid, electrolytes and feeding formula

What should be done if a patient who is volume restricted has constipation? A. Give extra fluids followed by diuretics B. Add fiber supplements C. Add a stool softener and a laxative or cleansing enema D. Decrease EN formula infusion

C. Add a stool softener and a laxative or cleansing enema If a patient has constipation and the usual hydration volume is contraindicated, the addition of a stool softener and a laxative or cleansing enema may be considered. However, chronic use of stimulants (eg senna) often results in tachyphylaxis and is not recommended for chronic constipation.

Abdominal distention in a patient with nausea indicates a need to monitor the abdomen closely, how frequently is recommended? A. Immediately after each bolus feeding or every 4 hours for continuous feeding B. Immediately after each bolus feeding or every 6 hours for continuous feeding C. Before the next bolus feeding or every 4 hours for continuous feeding D. Before the next bolus feeding or every 6 hours for continuous feeding

C. Before the next bolus tube feeding or every 4 hours for continuous feeding

Which of the following methods is not recommended to minimize contamination of enteral feeding formula? A. Washing hands and donning clean gloves before preparing enteral formula B. Immediate use of enteral formula from a newly opened container C. Infusing reconstituted powdered formulas or formulas with added modular components in 1 bag for up to 8 hours D. Changing an "open" feeding container every 24 hours

C. Infusing reconstituted powdered formulas or formulas with added modular components in 1 bag for up to 8 hours Formula prepared from reconstituted powder or with added modular components should be infused for no more than 4 hours. Infusion times greater than 4 hours are associated with formula contamination. Good handwashing technique, clean gloves and immediately using a newly opened formula container will minimize contamination. Changing an open feeding container every 24 hours will minimize bacterial growth.

Which of the following lab results suggest dehydration? A. Decreased BUN to creatinine ratio <20:1 B. Decreased Hematocrit C. Serum sodium levels can be elevated, low or normal depending on the etiology of the dehydration D. Decreased plasma osmolality

C. Serum sodium levels can be elevated, low or normal depending on the etiology of the dehydration These labs would be elevated relative to pre-dehydration levels in dehydrated patients: 1. BUN 2. Plasma osmolality 3. Hematocrit Serum sodium levels can be elevated, low or normal depending on the etiology of the dehydration BUN level usually rises out of proportion to the usual BUN to creatinine ratio of 20:1

Which of the followings is not an appropriate intervention if delayed gastric emptying is suspected? A. Changing from bolus to continuous feeding B. Administering a prokinetic agent C. Switching to a high fat formula D. Reducing the infusion rate

C. Switching to a high fat formula Appropriate interventions if delayed gastric emptying is suspected: 1. Reducing or discontinuing narcotic medications 2. Switching to a low fiber, low fat and/or isotonic formula 3. Administering the feeding solution at room temperature 4. Temporarily reducing the rate of infusion by 20 to 25 mL/hr 5. Changing the infusion method from bolus to continuous 6. Administering a prokinetic agent such as metoclopramide or erythromycin

Clinical manifestations of maldigestion and malsborption include the followings except? A. Abdominal distention B. Steatorrhea C. Unexplained weight gain D. Micronutrient deficiency

C. Unexplained weight gain Clinical manifestations of maldigestion and malabsorption include: 1. Bloating 2. Abdominal distention 3. Diarrhea 4. Unexplained weight loss 5. Steatorrhea 6. Signs of vitamin, mineral, or essential macronutrient deficiency

Causes of hypokalemia in TF patients include: i. Refeeding syndrome ii. Diuretic therapy iii. Excessive losses (diarrhea, NGT) iv. Metabolic acidosis A. i B. i and ii C. i, ii and iii D. all of the above

C. i, ii and iii 1. Refeeding syndrome 2. Catabolic stress 3. Depleted body cell mass 4. Effect of ADH and aldosterone 5. Diuretic therapy 6. Excessive losses (diarrhea, NGT) 7. Metabolic alkalosis 8. Insulin therapy 9. Dilution

How much sorbitol is needed to cause diarrhea? A. 5-10 mg B. 10-20 mg C. 5-10 g D.10-20 g

D. 10-20 g As little as 10 to 20 g of sorbitol can lead to GI side effects

What are the causes of hypophosphatemia in TF patients? i. Refeeding syndrome ii. Excessive energy intake iii. Binding by epinephrine iv. Sucralfate, antiacids A. i B. i, ii C. i, iii, iv D. All of the above

D. All of the above Causes of hypophosphatemia in TF patients: 1. Refeeding syndrome 2. Excessive energy intake 3. Binding by epinephrine 4. Sucralfate, antiacids 5. Insulin therapy

What would you consider when a patient is at risk of intestinal ischemia? A. Initial use of an isotonic enteral formula B. Initial use of fiber-free enteral formula C. Monitor acute changes in abdominal assessment D. All of the above

D. All of the above Considerations when a patient is at risk of intestinal ischemia: 1. Initial use of an isotonic and fiber-free enteral formula 2. Acute changes in abdominal assessment can prompt early recognition and treatment of NOBN. A patient who previously demonstrated EN feeding tolerance and then develops abdominal distention, abdominal pain, and an acute change in nasogastric tube output should be fully evaluated

Which of the followings increase risk of EN formula contamination? i. Retrograde migration of endogenous microorganisms into the EN delivery system ii. Interruption of formula infusion iii. Checking GRVs iv. A biofilm is formed at the Lopez valve A. i and iii B. i and iv C. ii and iii D. All of the above

D. All of the above EN formulas may become contaminated in a retrograde manner if the patient's endogenous microorganisms reproduce within the feeding tube and then migrate into the EN delivery system. May then proliferate within the feeding formula and be reinfused to the patient in greater numbers. Most EN delivery tubing systems contain a drip chamber that minimizes the occurrence of this problem. If formula infusions are interrupted the stagnant period could allow microorganisms to proliferate. Checking GRV pulls potentially pathogenic microorganisms up the feeding tube. Can lead to a contaminated feeding tube hub and contaminated gloves. Lopez valves are 3-way stopcocks that are frequently attached to feeding tubes that do not contain a clamp (NGT, balloon gastrostomy, balloon gastrojejunostomy and jejunostomy tubes). It swivels to block or allow fluid passage. Biofilms are resistant to antibiotics and the patient's own immune response and can cause acute or chronic infections. Lopez valves should be changed at intervals of 3 days or less and perhaps at each tubing change.

Which of the following can influence accuracy of GRV? A. Diameter and position of the tube tip B. Patient's position altering the level of stomach fluid C. Skill of the clinician D. All of the above

D. All of the above Elevated GRVs can predict vomiting or reflux, clinicians have used GRV to determine the risk for aspiration. However, accuracy of GRV is influenced by the following factors: 1. Diameter and position of the tube tip 2. Number and location of the tube's openings 3. Patient's position altering the level of stomach fluid 4. Skill of the clinician

Preventative measures/therapies for dehydration or overhydration in TF patients include: i. Monitor daily fluid I/O ii. Monitor body weight daily iii. Monitor serum electrolytes, Bun and Creatinine daily iv. Provide fluid or diuretics as indicated A. i and ii B. ii and iii C. iv D. All of the above

D. All of the above Preventative measures/therapies for hypertonic dehydration include: 1. Monitor daily fluid I/O 2. Estimate fluid losses 3. Monitor body weight daily 4. Monitor serum electrolytes, urine-specific gravity, BUN and Cr daily 5. Provide enteral or IV fluid as indicated Preventative/therapies for overhydration include: 1. Monitor I/O daily 2. Assess fluid status daily 3. Monitor body weight daily 4. Check aldosterone levels, which will be elevated with sodium retention 5. Consider use of less concentrated formula 6. Diuretic therapy

Fluid intake should be increased if patient has which of the following signs or symptoms? i. Fever ii. Emesis iii. Diarrhea iv. High fistula or ostomy outputs A. i and ii B. ii and iii C. iii and iv D. All of the above

D. All of the above Signs or symptoms that need additional fluid intake: 1. Fever 2. Emesis 3. Diarrhea 4. High fistula or ostomy outputs 5. Hyperglycemia

Which of the following statements is wrong? A. BUN reflects protein intake, hydration, and renal function. B. Patients with renal failure and no protein intake may have a normal or even low BUN concentration. C. Patients with renal failure and no protein intake may have a normal or even high BUN concentration. D. All statements are correct.

D. All statements are correct BUN reflects protein intake, hydration, and renal function. Patients with renal failure and no protein intake may have a normal or even low BUN concentration

Which of the followings is not a sign of intravascular volume depletion in acutely ill patients? A. Increased heart rate B. Decreased or more concentrated urine C. Increase in oxygen extraction D. Decreased Bun/Cre ratio

D. Decreased Bun/Cre ratio Signs of intravascular volume depletion include: 1. Increased heart rate 2. Decreased or more concentrated urine 3. Increase in oxygen extraction (an increase in the difference between arterial and venous oxygen concentration)

Common causes of diarrhea in EN patient include the followings except? A. Medications/drugs-induced diarrhea B. Primary GI disease C. Bacterial infection D. Fructo-oligosaccharides (FOS) in EN formula

D. Fructo-oligosaccharides (FOS) in EN formula Common causes of diarrhea in EN patients include: 1. Medications Drug-induced diarrhea 2. Primary GI disease 3. Bacterial infection Characteristics of the formula (osmolality, fat content) and specific components in the formula are less likely to cause diarrhea.

Which of the following is not a common cause of constipation? A. Dehydration B. Inadequate or excessive fiber C. Opioid use D. Regular physical activity

D. Regular physical activity Common causes of constipation include: 1. Dehydration 2. Inadequate or excessive fiber 3. Inactivity

What of the followings are potential causes of abdominal distention in enterally fed patients? i. C. diff colitis ii. Bowel obstruction iii. Excessively rapid formula infusion iv. Fiber-containing formula A. i and iv B. ii and iii C. ii and iv D. all of the above

D. all of the above Distention and vomiting may be caused by, ileus, obstruction, obstipation, ascites or diarrheal illness such as Clostridium difficile colitis. Excessively rapid formula administration or infusion of very cold formula may contribute to abdominal distention. Fiber containing formulas can cause abdominal distention because fiber ferments and produces gas in the gut. The role of fiber in slowing gastric emptying may also be a factor.

What are the management strategies for diarrhea? A. Rule out infection/inflammatory causes, fecal impaction, or diarrheagenic medications. Use antidiarrheal agent once C-Difficile infection has been ruled out or treated. B. Change TF formula to peptide- based formula. C. Add soluble fiber or insoluble fiber. D. Supplement with PN if EN cannot meet macro and micronutrient needs. E. All of the above

E. All of the above Management strategies for diarrhea: 1. Medical assessment of the patient to rule out infectious or inflammatory causes, fecal impaction, diarrheagenic medications 2. Use of an antidiarrheal agent (loperamide, diphenoxylate, paregoric or octreotide) once C.difficile infection has been ruled out or is being treated 3. Changing the formula type (intact protein product to a peptide-based formula) 4. Addition of soluble fiber or insoluble fiber to the medication regimen and/or changing to an enteral formula with added fiber, except in unstable critically ill patients 5. Continuation of EN as tolerated and initiation of PN to complete delivery of macro and micronutrients if intolerance or malabsorption is severe and prolonged

Which of the following is/are risk factors for increased incidence of aspiration? A. Vomiting B. Paralysis C. High sedation D. Transportation within the hospital E. All of the above

E. All of the above Risk factors for increased incidence of aspiration: 1. Low HOB elevation 2. Vomiting 3. Gastric tube feedings (as opposed to small bowel feedings) 4. Low Glasgow coma score 5. GI reflux disease 6. Paralysis 7. High sedation 8. Malpositioned feeding tube 9. Transportation within the hospital 10. Inadequate nursing staff