NUTRITION SUPPORTNoraishah Mohamed Nor

Dept Nutrition Sc

IIUM

INTRODUCTION

CONDITIONS THAT REQUIRE SPECIALIZEDNUTRITION SUPPORT

Enteral—Impaired ingestion—Inability to consume adequate nutrition orally—Impaired digestion, absorption, metabolism—Severe wasting or depressed growth

ParenteralGastrointestinal incompetency (diminished

intestinal fx)Hypermetabolic state with poor enteral

tolerance or accessibilitySupplement to EN

CONDITIONS IN ENDiminished food intake

Preoperative malnutritionComaPostoperative ileus

Hypercatabolic statesPolytraumaBurnSepsisSevere disease condition

Diminished digestion and absorptionPyloric stenosisPancreatic diseaseBiliary diseaseMalabsorbtion syndromeShort bowel syndromeRadiation enteritisUlcerative colitisDuodenal fistula

Chronic diseaseChronic cardiac, hepatic, renal diseaseMalignant disease

Changes in metabolic rate and nitrogen excretion with various types of physiologic stress

INDICATIONS FOR ENTERAL NUTRITION

Inadequate amount nutrients and/or calories ingested will lead to malnutrition- associated with an increased incident of: Poor wound healingImpaired immune response and

response to traumaIncreased risk of sepsisAltered gut structure/function

causing malabsorption and spread of bacteria

Ultimately malnutrition will lead to: Prolong recovery period Increased need for nursing care Increased risk of serious complications Prolong hospital stay Increased medical cost

CONTRAINDICATIONS FOR EN

Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Inadequate resuscitation or hypotension;

hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if

malnourished or 7-9 days if normally nourished

ADVANTAGES - ENTERAL VS PN

Preserves gut integrity Possibly decreases bacterial translocation Preserves immunological function of gut Reduces costs Fewer infectious complications in critically

ill patients Safer and more cost effective in many

settings

ADVANTAGES - ENTERAL NUTRITION

Intake easily/accurately monitored Provides nutrition when oral is not possible

or adequate Supplies readily available Reduces risks associated with

disease state

DISADVANTAGES—ENTERAL NUTRITION

GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax

Costs more than oral diets (not necessarily) Less “palatable/normal”: patient/family

resistance

Labor-intensive assessment, administration, tube patency and site care, monitoring

DISADVANTAGES - PN

Gut mucosal athropy Overfeeding Hyperglycemia Increased risk of infectious complications Increased mortality in critically ill pt

AIMS OF NUTRITIONAL SUPPORT

Preserve lean body mass (protein) Increase protein synthesis Improve immune and muscle function More rapid recovery Shorten hospital stay Reduction of morbidity

ROLES OF NUTRITION SUPPORT DIETITIAN

Working with other health care professionals inc. pharmacist, nurse, clinician-to support, restore, maintain optimal nutritional health for individuals with potential or known alterations in nutritional status

Assures optimal nutrition support though implementation of nutrition care process related to delivery of EN and PN support (Fuhrman et al 2001)

Nutrition care process

Individual nutritional status assessment

Indentify nutritional diagnosis

Implement appropriate interventions

Monitor & reassess an individual’s response to the nutrition

care delivered

Evaluate outcomes-incl. the need for transitional feeding care plan or termination of nutr. Support intervention

(Lacey & Pritchett, 2003)

ALGORITHM TO CHOOSE NUTRITIONAL SUPPORT

Nutritional assessment of the patient

Normally nourishedNormally nourished but will develop malnutrition because of disease process if support withheld

malnourished

Normal feeding Nutritional support indicated

DIFFERENT WAYS TO PROVIDE NUTRITION SUPPORT

Oral Enteral Parenteral Combined

WHEN THE GUT WORKS – USE IT!

SIGNS OF FUNCTIONING GIT

The present of bowl sound Soft, non-tender abdomen Passage of fistulas/stool Intact appetite

ENTERAL NUTRITION BY MOUTH

Common sense Adequate Palatable Varied Nutritional complete Provided at regular intervals, more frequentyly

than regular meal times if necessary Progressively increasing in heaviness and

complexity

Cleanliness In preparation and serving of food and utensils to

prevent GIT infection

Compassion Ensuring the patient ingests the preferred food Putting food in patient’s reach Conducive eating environment Involving dietitians in food selection and preparation

ENTERAL NUTRITION BY TUBE Nutrition provided through the gastrointestinal tract via a tube,

catheter, or stoma that delivers nutrients distal to the oral cavity

Benefits of EN: Help maintain gut mucosal physiology

May modulate immune response-prevent translocation of bacteria and toxins (maintain gut mucosal integrity)- IgA in EN (IgA prevent absorption of enteric antigents)-less risk for infection

Promote peristalsis

Safer: fewer complication

Lower cost-formula, delivery system and less patient care

Simpler system-care and self-administrator

CLINICAL SETTING IN WHICH ENTERAL NUTRITION SHOULD BE PART OF ROUTINE CARE

PEM with inadequate oral intake of nutrients for the previous 5 days

Oral intake <50 % of required needs for the previous 7-10 days

Severe dsyphagia due to strokes, brain tumors, head injuries, multiple sclerosis

Major (>30 % of BSA), full thickness burns

Short gut due to small bowel resection-enteral nutrition + parenteral nutrition to stimulate regeneration of the remaining intestine

Clinical conditions in which enteral nutrition usually may be helpful:

Major trauma with functional GIT + inadequate oral intake for 7-10 days

Radiation therapy for cancers of the lungs, head, neck and cervix, and lymphomas

Acute/chronic liver failure + severe anorexia + functioning GIT

Severe renal dysfunction (<5% of normal glomerular filtration) + anorexia + functioning GIT

Contraindications for enteral feeding: Mechanical obstruction of GIT Prolong ileus Severe GI haemorrhage Severe diarrhoea Intractable vomiting High-output GIT fistula (>500 ml/day) Severe enterocolitis

TUBE FEEDING ROUTES

TRANSNASAL PASSAGE

Transnasal passage of feeding into the stomach/intestine employed when possibleA surgical procedure can be avoidedGenerally well tolerated when small-bore

feeding tube are usedDisadvantages:

tube can be readily removed by disorientated/uncooperative px.

When larger, stiffer tube used-irritation to nasal passages, pharynx, esophagus & compromise gastroesophageal competency

Nasogastric insertion & placement of the tube is easier.

Nasogastric, esophagostomy, gastrostomy feeding allow the digestive process to begin in

the stomach-decreasing risk of dumping syndrome.

Disadvantage:higher risk of aspiration-only gastroesophageal sphincter is operating to prevent reflux

Nasoduodenal, nasojejunal, jejunostomy:Advantage:

Posed less risk of regurgitation-advantage of gastroesophageal sphinctar & pyloric sphincters

Disadvantages: Higher risk of intolerance (nausea,

vomiting, diarhea, cramps)-when feeding are not properly selected.

The bactericidal effect of HCL in the stomach is bypassed-need attention for sanitation to formula and equipment

OSTOMIES

Require surgical insertion. Indicated when insertion through

transnasal is impossible or when long-term feeding is anticipated

Advantages: irritation caused by the feeding tube is

eliminatedOstomies are unobtrusive between feeding

time

Jejunostomies: Advantage:

permits early post operative feeding (unlike stomach & colon)-the small bowel is not affected by postoperative ileus.

Relatively safe, comfortable, potential for long-term use

Disadvantage: Possibility of infection is high like

other ostomy procedure

EN ADMINISTRATION

Administration of EN should be guided by: Px’s age Underlying disease Enteral access device Condition of GI

When the patient should be started with EN? Eary initiation of EN is beneficial if px is

hemodynamically stable In ICU, when EN was initiated within 24-48 hrs

of admission: Lower rates of infection Shorter hospital stay

(Bar et a. 2004)

METHODS OF DELIVERY

Based on: Nutrient needs Feeding site Formula selection Current medical status

3 methods of delivery:1. Bolus feeding2. Intermittent bolus feeding3. Continuous feeding

Bolus feeding:Administered using a syringe/feeding reservoir Infused over a period of timeTolerance is dependent on the functional

ability of the gutGenerally, the px is fed a vol of 250-400ml of

formula-5-8x/dayAllow px greater freedom/movement between

feeding timesAssociated with high incidence of

complications: Nausea Vomiting Diarrhoea Abdominal distension & cramps Aspiration

Intermittent bolus feeding:Administered by slow gravity dripEach feeding is given over 30 min every 3-4

hrsTolerance is dependent in the functional ability

of the gut Initiation of feeding with 50 ml of isotonic formula

(<30ml/min) every 3-4 hrs Progression of feeding regime with additional 50 ml

every 8-12 hrs as tolerated

Generally, prescribed vol of formula 250-400 ml infused over a 20-30 min period 5-8x/day

Allow px greater freedom/movement between feeding times.

Complications can be similar to bolus feeding

Continuous feeding Utilised when bolus/intermittent feedings are not

tolerate/in critical ill patients/small bowel feeding

Usually pump assisted

Associated with reduced incidence of high gastric residual, GER and aspiration

Restricts px movement

Continuous tube feedingi. Initiation of tube feeding range from 20-

50ml/hrii. Progression of tube feeding range from 10-

20ml/hr every 8-24 hrs until the desired volume is attained

iii. the strength can be increased as tolerated.iv. If feeding is not tolerated-reduce the rate &

strength to previously tolerated level-gradually increase the rate & strength again

v. Avoid altering rate & strength at the same time

PART 2--NUTRITION SUPPORT FOR CRITICALLY ILL

ENERGY REQUIREMENT1. Haris Benedict Equation

Male REE = 66.47+13.75W+5.0H-6.76AFemale REE = 665.10+9.56W+1.85H-4.68A

W= wt in kg H = ht in cm A = age in years

2. Formula FAO/WHO/UNU (1985)  Male 18 – 30 REE = 15.32W+679 30 – 60 REE = 11.2W+879 >60 REE = 13.5W+987

Female 18 – 30 REE = 14.7W+496 30 – 60 REE = 8.7W+829 >60 REE = 10.5W+596

3. Ismail et al.(1998)Men

18 – 30 years:BMR=0.0550(W)+2.480 MJ/d30 – 60 years:BMR=0.0432(W)+3.112 MJ/d

 Women

18 – 30 years:BMR=0.0535(W)+1.994 MJ/d30 – 60 years:BMR=0.0539(W)+2.147 MJ/d

ACTIVITY AND STRESS FACTORS

Activity Factor=1.0 – 1.1 (bed rest)= 1.2 – 1.3 (very light) =1.4 – 1.5 (light)= 1.6 – 1.7 (moderate activity)=1.9 – 2.1 (highly active)= 2.2 – 2.4 (strenuous)

Stress Factor :

=1.1(mild malnutrition, postoperate no complication=1.2(mild illness confined to bed)=1.3(mild illness ambulatory)=1.2-1.3 (surgery major)=1.3-1.4 (trauma skeletal)=1.2 – 1.3(mild infection and stress)=1.4 – 1.5(moderate infection and stress)=1.6 – 1.8(severe hypercatabolic)=2.0 – 2.2(sepsis)=1.2 – 1.4(<20%BSA)=1.5 – 1.7(20 – 40%BSA)=1.8 – 2.0(>40%BSA)=1.2 – 1.3(Fracture)=1.4 – 1.5(respiratory or renal failure)=1.4 – 1.8(COPD)=1.5 – 1.6(Cancer with chemo or radiation,cardiac cachexis)

TYPES OF ENTERAL PRODUCTS

Standard/polymeric formulas Elemental Modular (Supplements) Condition Specific

Polymeric formula Composed of intact proteins,

disaccharides,polysaccharides, variable amounts of fat and residue

Require a functioning GIT for absorption and digestion

Category Characteristic Indication Products

Standard •Nutritionally complete•Provide 1 kcal/ml•Distribution:

50-60 % CHO10-15 % Protein25-30 % fat

Normal digestive & absorptive capacity

Ensure/Nutren Optimum/Osmolite

Fiber-suplemented

•Similar to standard formula except for fibre content•4 – 20g of dietary fibre/l

Constipation, diarrhoea

Jevity/ Nutren Fibre/Nutren Diabetic

Category Characteristic Indication Products

Concentrated Similar to standard formula except provide 1.5 – 2.0 kcal/ml

Fluid restriction Ensure Plus, Enercal Plus

Elemental formula Partially hydrolyzed protein

Characteristic Indication Products

Nutritionally completeUsually provide 1 kcal/ml

May contain glutamine

Reduced digestive & absorption capacity e.g. Crohn’s Disease, Short Bowel Syndrome, long term fasting with gut atrophy, post operative patients

Peptamen/AlitraQ, Elementum

Modular FormulasSingle nutrient supplement, nutritionally incomplete, usually low in electrolytes

Examples : Fat-MCT oil (Medium Chain Triglyceride) CHO- Carborie, Polycose (Glucose polymer) Protein- Myotein

Condition specific productsCondition Characteristic Indications Product

Metabolically stress

•Nutritionally complete•Provides 1.5 kcal/ml•High in protein: >20% kcal•May contain: arginine,nucleotides, omega-3 fatty acids

Polytrauma /post operative period (following major surgeries)

Perative

Hepatic Encephalopathy

•Protein content: high in BCAA, low in Aromatic Amino Acids

Hepatic Encephalopathy

Falkamin

Protein, electrolyte and fluid restriction

•Provides 2.0 kcal/ml•Low in protein•Low in phosphorous

Acute or chronic kidney disease not on dialysis

Suplena (NA)

Glucose Intelorance

•Nutritionally complete•Provides 1.0kcal/ml•Low in CHO: 35% of kcal•High in fat: 40-50% of kcal•Fibre supplemented

Hyperglycaemia :> 10mmol/L

Glucerna/ Nutren Diabetik/ Nutricomp®

Diabetic

Condition Characteristic Indications ProductCO2 retention •Nutritionally complete

•Provides 1.5 kcal/ml•High in fat: 55% kcal &•Low in CHO: 30% kcal

Chronic obstructive pulmonary disease with CO2 retention

Pulmocare

Electrolyte and Fluid restriction

•Provides 2.0 kcal/ml•Moderate in protein•Low in phosphorous

Acute or chronic renal failure requiring dialysis

Nepro/ Nutricomp® Renal

IMMUNE-ENHANCING FORMULAS

Have added “immune-enhancing” nutrients (arginine, glutamine, omega-3 fatty acids, nucleotides)

Results of research have been mixed

Multiplicity of active ingredients makes it difficult to control variables

Meta-analysis suggests that they might be most beneficial in surgical patients

Some evidence of harm in septic patients

EVIDENCE- BASED Glutamine should be added to standard formula

in: Burn & trauma patients

In Burns pt, the trace elements (Cu, Zn, Se) should be supplemented in higher dose

For the trauma patient, it is not recommended to routinely use immune-enhancing EN, as its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation.

Diet supplemented with arginine should not be used for critically ill pts.

FORMULAS FOR IMPAIRED GI FX: INFANT/CHILDREN

Protein Hydrolysate Pregestimil Alimentum

Peptide/ Elemental Neocate Peptamen Jr. Vivonex Pediatric Neocate advance

INITIATION OF FEEDING

Choose full strength, isotonic formulas for initial

feeding regimen.

Initiation and advancement of enteral formula in

pediatric patients is best done over several days

in a hospital setting using a flexible nutrition

plan.

INITIATION OF FEEDING- PAEDIATRIC

Continuous feeding Generally children are started

isotonic formula at a rate of 1-2 mL/kg/h for smaller children

1mL/kg/h for larger children over 35-40 kg. The rate is advanced based on tolerance by the child the goal of providing 25% of the total calorie needs on

day 1.

Bolus feeding 2.5-5 mL/kg can be given 5-8 times per day with

gradual increases in this volume to decrease the number of feedings to closer to 5 times daily.

INITIATION OF FEEDING-CHILDREN

Bolus feedings & gravity-controlled feedings started with 25% of the goal volume divided into

the desired number of daily feedings. Formula volume may be increased by 25% per

day as tolerated, divided equally between feedings

Pump-assisted feedings A full-strength, isotonic formula can be started

at 1-2 mL/kg/h and advanced by 0.5-1 mL/kg/h every 6-24 hrs until the goal volume is achieved

For preterm, critically ill, or malnourished children Use pump initial volume : 0.5-1 mL/kg/hour Advancing to 10-20 ml/kg/day

INITIATION OF FEEDING-ADULTS

Bolus feedings & gravity-controlled feedings full-strength formula 3-8 times per day increases of 60-120 mL every 8-12 hours as

tolerated up to the goal volume.

Pump-assisted feedings initiated at full strength at 10-40 mL/h and

advanced to the goal rate in increments of 10-20 mL/h every 8-12 hours as tolerated

PATIENT POSITIONING

Elevate the backrest to a minimum of 30º-45º, for all patients receiving EN unless a medical contraindication exists. Eg.unstable supine, hemodynamic

instability, prone position

If necessary to lower the Head-to-bed (HOB) for a procedure or a medical contraindication, return the patient to HOB elevated position as soon as feasible.

FLUSHES-PRACTICE RECOMMENDATIONS

Flush feeding tubes with 30 mL of water every 4

hours during continuous feeding or before and after intermittent feedings in an adult patient

flush the feeding tube with 30 mL of water after residual volume measurements in an adult patient

Flushing of feeding tubes in neonatal and pediatric patients should be accomplished with the lowest volume necessary to clear the tube

MEDICATION ADMINISTRATION

Do not add medication directly to an enteral feeding formula.

Avoid mixing together medications intended for

administration through an enteral feeding tube to reduce risks of:physical and chemical incompatibilities,tube obstructionaltered therapeutic drug responses

Dilute medication appropriately prior to administration.

REFEEDING SYNDROME

Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding.

These complications are often worsened by overfeeding or by use of aggressive repletion.

PHYSIOLOGIC CHANGES OCCUR DURING REFEEDING

Intracellular mineral depletionHypophosphatemiahypomagnesemia,Hypokalemiabody fluid disturbances (“refeeding

edema”)vitamin deficiencies (eg, thiamine)

lifethreateningcardiac arrythmiasrespiratory arrestCongestive heart failure

CONSEQUENCES OF ELECTROLYTE ABNORMALITIES

Electrolytes Consequence PO4 Acute ventilatory failure

Arrythmias Confusion Congesive heart failure Lethargy, weakness Rhabdomyolysis

K+ Arrythmias Cardiac arrest Constipation / ileus Polyuria / polydipsia Respiratory depression Weakness

Mg2+ Anorexia Arrythmias Confusion Diarrhoea / constipation Weakness

PATIENTS AT HIGH RISK OF REFEEDING

Patients with any of the following: BMI < 16 kg/m2

Unintentional weight loss >15% within the last 3-6 months

Very little or no nutrition for >10 days

Low levels of potassium, magnesium or phosphate prior to feeding

Patients with 2 or more of the following: BMI < 18.5 kg/m2

Unintentional weight loss >10% within the last 3-6 months

Very little or no nutrition for >5 days

A history or alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics

MONITORING FOR REFEEDING SYNDROME

Monitoring metabolic parameters prior to the

initiation of EN feedings and periodically during EN therapy should be based on protocols

Prevention of refeeding syndrome is of utmost importance

Px at high risk for refeeding syndrome and other

metabolic complications should be followed closely, and depleted minerals and electrolytes should be replaced prior to initiating feedings.

Patients at risk of developing refeeding syndrome

should be identified, electrolyte abnormalities should be corrected prior to the initiation of nutrition support.

Nutrition support should be initiated at approximately 25% of the estimated goal and advanced over 3-5 days to the goal rate.

Serum electrolytes and vital signs should be monitored carefully after nutrition support is

started

CHALLENGES IN NUTRITIONAL SUPPORT

1. Caloric requirement not met Under ordering by physician Reduced delivery Slow advancements

2. Gut dysfunction High residual volume (GRV) Nausea Vommiting Absent of bowel sound Diarrhea Aspiration

3. Procedure and diagnostic test require fasting

4. Lack of enthusiasm, personal bias and individual practice

THE RISK FACTORS FOR ASPIRATION

Sedation supine patient positioning the presence and size of a nasogastric tube malposition of the feeding tube mechanical ventilation, vomiting bolus feeding delivery methods poor oral health nursing staffing level advanced patient age

STRATEGIES TO OPTIMIZED DELIVERY & MINIMIZED RISK

1. Use feeding protocol2. Motility agent (eg. Prokinetic)3. Small bowel vs gastric feeding4. Body position5. Nutrition support practice

FEEDING PROTOCOL

e.g. Prospective evaluation before and after evidence based protocol introduction of EN in surgical pt.. Within 24 – 48 hrWith the protocol:

Inceased delivery of nutirentsShortened duration of mechanical ventilation

Decrease mortality

PROKINETIC AGENT: METOCLOPRAMIDE

IV administration of metoclopramide or erythromycin should be consider in pt with intolerance to EFE.g with high gastric volume

LEVELS OF GRV

Severity Definition Treatment

Mild <200 ml •Return GRV•Continue feeding

Moderate

200 – 500 ml •1st episode continue•2nd episode start prokinetic agent• 3rd episode reduce EN by half• 4th episode:

• Stop feeding• Place NJ tube• Start EN protocol again

Severe > 500 ml •Stop gastric feeding•Place NJ tube•Start EN protocol

Refer MNT pg 10 other assessment of tolerance

SMALL BOWEL FEEDING

Small bowel fed pt have improved energy delivery in some studies

Duodenal vs gastric feeding in ventilated blunt trauma ptImproved tolerance of EN and consequent faster achievement of desired calories

Kortbreek JB J Trauma

Small bowel vs gastric feedingMaybe associated with a reduction

in pneumonia in critically ill ptNo different in mortality or

ventilation daysSmall bowel feeding improves cal &

prot intake and is associated with less time taken to reach target rate of enteral nutrition.

NUTRITION SUPPORT PRACTICES

How should pt be tube fed after surgery?TF should be initiated within 24 hr after surgery

Sholud satrt with low flow rate (e.g 10 -20 (max) ml/hr)due to limited intestinal tolerance

May take 5 – 7 days to reach the target intake

Not consider harmful

ESPEN guideline 2006

NUTRITION SUPPORT PRACTICES

DO NOT…………..:1. Assemble feeding system on the pt’s

bed2. Top up fresh formula until the

formula hanging in the feeding bag has finished

3. Overfed patients: High calorie density formula

1.3 kcal/ml Perative 1.5 kcal/ml Pulmocare 2.0 kcal/ml nepro/enercal plus

OPEN VS CLOSED SYSTEM

Open System:Product is decanted into a feeding

bagAllows modulars such as protein and

fiber to be added to feeding formulasLess waste in unstable patients

(maybe)Shortens hang time Increases nursing timeIncreased risk of contamination

Closed System or Ready to Hang:Containers sterile until spiked for

hanging

Can be used for continuous or bolus delivery

No flexibility in formula additives

Less nursing time

Increases safe hang time

Less risk of contamination

More expensive than canned formula

Open System

Hang time 8 hours for decanted formula; 4 hours for formula mixtures

Feeding bag and tubing should be rinsed each time formula replenished

Contaminated feedings are associated with pt morbidity

Closed System

Hang time 24-48 hours based on mfr recommendations

Y port can be used to deliver additional fluid and modulars

May result in less formula waste as open system formula should be discarded p 8 hours

CONCLUSIONo Practice early enteral feeding

o Use strict protocols

o Modify preoperative preparation

o Identify & rectify tube displacement

o Consider tube placement post pyloric

o Alter method of feeding (routine cycling, smaller o volume, concentrated feeds)

o Works as Nutrition Support Team

o Continuous Nutrition Education

THANK YOU….Q???

TUTORIAL 1. Male, age 39, 189 cm tall. 91 kg body

weight, confined to bed and having burn of 40% TBSA and body temp is 39°. Calculate calorie req and plan a EN regimen.

2. Female, age 41, 160 cm tall. 67 kg body wt. confined to bed and ventilated. Diagnosed with COPD. Calculate cal req and plan for EN regimen through pump feeding

3. Pt with TPN, Patient on Nutriflex (peripheral) for three days after operation (75 ml/hr)

1. Calculate the calorie from the TPN2. How to manage the pt if dr plan to change to

EN