Early parenteral nutrition alone or accompanying enteral ...
Basics of enteral and parenteral nutrition
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Transcript of Basics of enteral and parenteral nutrition
Basics of enteral and parenteral nutrition
Surgical Nutrition Training ModuleLevel 1
Philippine Society of General SurgeonsCommittee on Surgical Training
Objectives
• To discuss the different feeding pathways for the surgical patients
• To define and discuss key points of enteral and parenteral nutrition
• To discuss the monitoring process and expected outcomes for surgical patients
Feeding PathwaysCan the GIT be used?
Yes No
Parenteral nutritionOral
< 75% intake
Tube feed
Short term Long term
Peripheral PN Central PNMore than 3-4 weeks
No Yes
NGT
Nasoduodenal or nasojejunal
Gastrostomy
Jejunostomy
“inadequate intake”
“Inability to use the GIT”
A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and
enteral nutrition in adult and pediatric patients, III: nutritional assessment –
adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.
EARLY ENTERAL NUTRITION
Early enteral nutrition: definition
• Enteral nutrition that is initiated within 24 – 48 hours following hospitalization, trauma, or injury
Zaloga GP. Crit Care Med 1999; 27: 259
Why early enteral nutrition?
• The normal and designed route for nutrient intake, digestion, and absorption
• Immunocompetence is a major function of the gastrointestinal tract
• Non-utilization of the gastrointestinal tract even on a short term basis leads to complications in critical care or geriatric patient management
• Cost-effective
Early enteral feeding: goal
• To maintain intestinal mucosal integrity
– Normal microvilli Height and number
– Normal intestinal barrier
– Intestinal mucosal immunity
Early enteral feeding: rationale • Provide nutrients required during metabolic
stress• Maintain GI integrity• Reduce morbidity compared with parenteral
nutrition• Reduce cost compared with parenteral
nutrition
Early enteral nutrition vs standard nutritional support on mortality
Comparison: mortalityOutcome: early enteral nutrition vs. control
Study Treatment n/N
Control n/N
Cerra et al 1990
Gottschlich et al, 1990
Brown et al, 1994Moore et al, 1994Bower et al, 1996Kudsk et al, 1996
Engel et al, 1997
Weimann et al, 1998
1/11
2/17
0/191/51
24/1631/16
7/18
2/16
1/9
1/14
0/182/47
12/1431/17
5/18
4/13
0.01 0.1 10 100Higher for control Higher for treatment
Ross Products, 1996 20/87 8/83
Mendez et al, 1997 1/22 1/21
Rodrigo et al, 1997 2/16 2/13
Atkinson et al, 1998 96/197 86/193
Galban et al, 2000 17/89 28/87
Heyland et al. JAMA, 2001
Pooled Risk Ratio1
ENTERAL NUTRITION
Enteral nutrition accessSTOMACH JEJUNUM
Nasogastric tube Nasojejunal tube
PEG PEJ
BUTTON
PLG
JET-PEG
PLJ
NCJ
PSJ
PFJ
PSG
PFG
Witzel, Stamm, Janeway
Loser C et al. ESPEN guidelines on artificial enteral nutrition – Percutaneous endoscopic gastrostomy
(PEG)
E: EndoscopicG: GastrostomyJ: Jejunostomy
L: LaparoscopicNC: Needle CatheterS: Sonographic F: Fluoroscopic
Access and delivery
Nasogastric tube
PEG tube
Nasoentericor jejunal tube
Gastrostomy
PEG placement 0
10
20
30
40
50
60
70
80
90
100
nu
mb
er
2000
2001
2002
2003
PEG placement, St Luke’s Medical Center
Post-pyloric feeding
Gauderer MW, et al. J Pediatr Surg 1980;15:872-875
Short Term
Nasoenteric
– Nasoduodenal
– Nasojejunal
Long Term (operative)
Jejunostomy – Percutaneous endoscopic
jejunostomy or through the PEG tube
– Surgical jejunostomy
Enteral Formulas – what type?
• Polymeric formulas (80-90%) • Commercial (preferred)
• Blenderized (If not critically ill, not severely malnourished)
• Oligomeric formulas
• Disease-specific formulas
• Modular formulas (concentrated protein and carbohydrate preparations)
Enteral nutrition delivery
Gravity Feeding Enteral Pump Delivered
Practical points: enteral nutrition• If intake is within the range of 60% to 70% start oral
supplement– Choose the product or preparation that meets all the daily
requirements• If oral intake is 50% or less
– You may give parenteral nutrition to supplement (good for a week – expensive, but more comfortable for the patient)
– Cost-effective: NGT• If tube feeding duration will exceed 2 weeks and you
are looking at long term (stroke or critical care) – gastrostomy is easier to maintain with lesser complications (aspiration)
Practical points: enteral nutrition
• If patient will undergo surgery and you doubt patient will be able to have adequate intake for longer term:– Place gastrostomy during the surgery
• If gastric function return is in doubt for more than a week:
• Gastrostomy with jejunostomy tube extension• Surgical Jejunostomy
• Main goal: adequate intake
Enteral formula: commercial vs. blenderized
Commercial Formulas Blenderized Formulas
Uniform contentsSterile
Low viscosityLactose freeDefined caloric density
Daily nutrient variabilityNon-sterile; high bacterial content and other pathogensHigh viscosityDoes not provide adequate caloric density
Gallagher-Alfred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:268-273
Bacterial contamination in standard tube feeds
Standard Feed: measured vs. expected
Sullivan MM et al. Nutritional analysis of blenderized diets in the Philippines (PENSA 1998)
Commercial formula
Commercial formula Natural food formula
Natural food formula
• Monitor according to hospital protocol (e.g., every 3-4 hours)
• Volume not to exceed 50% of the amount infused
Mentec H, et al. Crit Care Med 2001;29:1955-1961
Monitoring Gastric Residuals
PARENTERAL NUTRITION
Parenteral nutrition: Indications
• To avoid periods of starvation within 24 to 72 hours when oral or enteral intake are insufficient to achieve adequate intake in moderate to severe malnourished patients
• When unable to use the gut– Gut obstruction– Short bowel (intestinal failure)– High output enterocutaneous fistulae– Non-functional gastrointestinal tract
ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009; 28(4): 359-479.
• Gut can be used:– Ability to consume and absorb adequate nutrients
orally or by enteral tube feeding– Hemodynamic instability– *Ineffective and probably harmful in non-aphagic
oncological patients in whom there is no gastrointestinal reason for intestinal failure.
Contraindications to PN
.* Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009; 28(4): 448.
Types of parenteral nutrition
Central• Amino acids ( > 5%)• Dextrose ( > 20%)• Lipids• Includes vitamins, minerals,
and trace elements• Carrier of pharmaconutrients
like glutamine or omega-3- fatty acids
• Osmolality ( > 700 mOsm/kg H2O)
• Volume restriction
Peripheral• Total kcal limited by
concentration and ratio to volume being administered (usually delivers between 1000 to 1500 kcal/day)
• The current formulations can now deliver the daily requirements of macro and micronutrients
• Osmolality < 700 mOsm/kg• No volume restriction
Types of parenteral nutrition
• Central parenteral nutrition
• Peripheral central parenteral nutrition
PICC =peripherally inserted central catheter
Catheters
Subclavian catheter (3 ports) PICC line catheters
Types of parenteral nutrition
• Peripheral parenteral nutrition
Central venous access
• Allows delivery of nutrients into the superior vena cava or right atrium
• Osmolarity - traditional cut off > 860 mOsm/L• Catheter differences :
– According to duration of use– Various lengths, gauges, and number of ports– Catheters treated with antibacterials
• Nutrient infusion via a dedicated catheter lumen
• Pittiruti M et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters. Clin Nutr 2009; 28(4): 365-7.
Formulations
• 1 Optimal nitrogen sparing is shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours.
• The different forms of PN packaging and delivery:– 2 Individualized– 2 Compounded– 1,2 “All in One”
1. Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382.2. Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2nd ed 2005; 97-107.
Formulation / Delivery
Break seal
Individualized delivery system
“All in one” placed in multi-chambered bags
• cheaper• stable• none to minimum contamination
Compounding / clean rooms
Development phases of the PN container system
Safety issues
Three in one bags: longer
storage and less contamination
Protocols:1.Compounding2.Incorporation – additives3.Delivery (access, rates of infusion, infusion pumps)
In-lineFilters:1.Fat emulsions2.Three in one solutions3.Micro-precipitates
EN/PN monitoring parameters
Assessment
• Nutrient balance (calorie & protein intake)
• Body weight• Nitrogen balance• Plasma protein (albumin,
pre-albumin)
Metabolic
• Glucose• Fluid and electrolyte
balance• Renal and hepatic function• Triglycerides and
cholesterol
• Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992
• Ch 17: parenteral nutrition. Total Nutrition Therapy ver. 2, 2003; 311-12.
Key monitoring points
• Fluid balance – avoid fluid accumulation within 4-5 days post op
• Calorie balance• Gastric retention for enteral nutrition• Blood tests:
– BUN high – dialyze– High triglycerides – lower lipid flow– Hyperglycemia – insulin
• Weight once a weekJan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003
OUTCOME IS DEPENDENT ON THE MONITORING PROCESS
Feeding PathwaysCan the GIT be used?
Yes No
Parenteral nutritionOral
< 75% intake
Tube feed
Short term Long term
Peripheral PN Central PNMore than 3-4 weeks
No Yes
NGT
Nasoduodenal or nasojejunal
Gastrostomy
Jejunostomy
“inadequate intake”
“Inability to use the GIT”
A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and
enteral nutrition in adult and pediatric patients, III: nutritional assessment –
adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.
Calorie, protein,
fluid balance
form
Nutrient monitor
form
Monitoring
DOCUMENTED OUTCOMES
Adequate intake in surgery patients
Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients
nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.
Nutrition team and intake
Llido et al. Nutrition team supervision improves intake of critical care patients in a private tertiary care hospital in the Philippines: report from
years 2000 to 2011 (for submission)
THANK YOU