Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus...
Transcript of Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus...
![Page 1: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/1.jpg)
Breiga Pepping Clinical Dietitian Dunedin Hospital
![Page 2: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/2.jpg)
Malnutrition State of nutrition in which a deficiency/excess (or
imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body forms or function and clinical outcomes
Protein Energy Malnutrition:• BMI <18.5 or weight loss of at least 5% in 6/12 (AND)
• evidence of suboptimal intake which has resulted in subcutaneous fat loss and/or muscle wasting
Malnutrition and overweight /obesity can co-exist
Regularly under-diagnosed and under-treated
![Page 3: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/3.jpg)
Implications of Malnutrition Reduced ability to fight infection
Inactivity and reduced ability to work, shop, cook, self care • inactivity can lead to pressure ulcers and blood clots
Falls
Reduced QOL
Impaired mental health- depression, introversion, self-neglect
Impaired wound healing
Impaired treatment tolerance i.e. cancer treatments
Financial:
LOS, hospital admissions/readmissions, health care costs
Treatment interruptions
![Page 4: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/4.jpg)
Artificial Nutrition Support Provision of nutrition support to meet nutritional
requirements in patients with inadequate oral intake
• sole source of nutrition
• supplementary nutrition
TPN/Enteral
• enteral feeding usually the most preferred method
• combination
![Page 5: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/5.jpg)
Indications Severe malnutrition
• weight loss >10%, muscle wasting, peripheral oedema
Moderately malnourished but would be expected to develop significant malnutrition due to underlying disease
Well nourished but unable to commence normal feeding for considerable length of time (>3-4d)
Unable to meet nutritional needs with oral intake alone
Unable to eat/drink safely i.e. dysphagia
![Page 6: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/6.jpg)
Contraindications for Enteral
Nutrition Major intra-abdominal sepsis
Total obstruction of gastrointestinal tract or
abdominal distension of unknown pathology
Malabsorption i.e. short bowel syndrome,
severe and intractable diarrhoea
![Page 7: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/7.jpg)
Benefits of Enteral Nutrition
• Lower cost compared with TPN
• Enteral feeding shown can decrease risk of
bacterial translocation and therefore
bacteraemia
![Page 8: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/8.jpg)
Goals of Enteral Nutrition• Achieve optimal nutritional status / hydration
• Correct significant nutritional deficiencies
• Achieve a satisfactory body weight
• Achieve normal metabolic parameters and fluid balance i.e. albumin, urea, creatinine, electrolytes, Hb.
• Allow for normal bowel function
• Facilitate the transition to oral intake when the clinical condition allows
• Reflect the wishes of the patient +/- their family
![Page 9: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/9.jpg)
Enteral Nutrition Types of enteral nutrition:
NGT/ NJT/ PEG/ PEJ/ RIG
Stomach (NGT/PEG/RIG) preferable option
can do both bolus and continuous feeding
Small bowel continuous feeding only
NGT/NJT vs PEG/PEJ/RIG length of time enteral support required
patients condition
Other considerations
![Page 10: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/10.jpg)
Possible Reasons for PEG • Neurological Diseases:
• Cerebrovascular
disease/stroke
• Motor Neuron disease
• Dementia
• Cerebral Palsy
• Multiple sclerosis
• Cancer
• Head and Neck / Oesophageal
• Burns
• Cystic Fibrosis
• Liver Disease
• Short bowel syndrome
• Chronic renal failure
• Head Injury
![Page 11: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/11.jpg)
Contraindications for PEG Serious coagulation disorders
Hemodynamic instability
Sepsis
Sever Ascites
Peritonitis
History of total gastrectomy
Gastric outlet obstruction (if for feeding)
Sever gastroparesis (if for feeding
Interposed organs i.e. liver, colon
Marked peritonitis, anorexia nervosa
Limited life expectancy
![Page 12: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/12.jpg)
Nutritional Assessment Anthropometry
height & weight
Biochemistry
Fluid & nutritional requirements
Food & fluid intake
Medications & interactions
Clinical condition CVA, cancer etc.
Social situation
![Page 13: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/13.jpg)
Feeding Considerations
Aim of enteral nutrition support
sole source of nutrition vs supplementary nutrition
weight maintenance/gain/loss
Formula type and amount
Feed administration
Aspiration Risk
Flushes: how many and when
hydration / keep enteral feeding tubes clean and patient
![Page 14: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/14.jpg)
Other Considerations: Refeeding Syndrome
Potentially fatal
Sever electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding
At risk if severely malnourished or very little or no food for more than 5 days
Common features sever fluid and electrolyte shifts → ↓P04, ↓K+, ↓Mg,
glucose abnormalities and thiamine and trace-element deficiencies
![Page 15: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/15.jpg)
Other Considerations: Refeeding Syndrome
Identify patients at risk before starting enteral nutrition
Baseline electrolyte level + ongoing monitoring until the patient is metabolically stable
Feeding needs to be started cautiously
Serum levels do not need to corrected prior to commencing nutrition support- can be corrected during nutrition support
![Page 16: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/16.jpg)
Medications Water flushes before and after is very important to
prevent blockages
Need to consider interactions with food, vitamins, electrolytes
medications that need to be given on an empty stomach
osmolality
sorbitol content
![Page 17: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/17.jpg)
Medications: Commonly Used in Enteral Feeding
Anti Nausea / Motility agents: Metoclopramide Ondansetron Erythromycin
Laxatives Coloxyl with Senna Laxsol Lactulose Movicol
Antidiarrhoeals Loperamide Codeine Phosphate
![Page 18: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/18.jpg)
Formulas Nutritionally complete
Lactose and gluten free
Range from 1-2kcal/ml
With or without fibre
Ready to hang
Closed system
1000ml or 500ml packs
Shelf life 24hrs after opening
12hrs if decanting
![Page 19: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/19.jpg)
Formulas
Polymeric (whole protein)
protein in the form it is normally within the diet
Pre-digested (peptide/semi-elemental/elemental)
protein as smaller molecules i.e.; short peptides or free
amino acids
malabsorption / allergies
Disease Specific
diabetes / renal / fluid restriction /
![Page 20: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/20.jpg)
Administration of Formula Bolus feeding
PEG / NGT only
Gravity / Syringe Push / Pump Bolus
usually over 5-6 feeds spread out over the day
Continuous feeding gastric and small bowel
via pump
feed continuously up to 24hrs a day
Combination bolus + continuous feeding
![Page 21: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/21.jpg)
Administration of Formula Considerations: inpatient
patients clinical condition
rehab vs acute setting
staffing
treatments/procedures
Considerations: Discharge Planning rest home/hospital level care vs Home
supports available
patients ability and wishes aim to reduce impact of enteral feeding on QOL
![Page 22: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/22.jpg)
Monitoring Gastric Residuals
when initiating NGT/PEG feeding
every 4hrs until feeding has reached goal rate
can only check if feeding into the stomach
Vomiting / Nausea anti nausea medication
rate/amount/type of feed
residuals
![Page 23: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/23.jpg)
Monitoring Abdominal distension, cramping
temperature of feed
speed bolus feeds administered
gastric residuals
constipation
![Page 24: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/24.jpg)
Monitoring Diarrhoea
medications e.g., sorbitol, magnesium, antibiotics
infection i.e. C Diff
resolving ileus
type of feed- osmolality/fibre
use of anti-diarrhoeal agents
Usual bowel habit
Temperature of feed
Administration rate of bolus feeds
Constipation fibre
fluid
medications- pain medications
decreased mobility
![Page 25: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/25.jpg)
Monitoring Biochemistry
K, Ca, PO4, Mg- refeeding
urea, creatinine, Na, Albumin / CRP
liver function- detect overfeeding
vitamin D
Dietary intake compare intake with requirements and enteral intake
facilitate weaning from enteral to oral intake
food charts / diet history
![Page 26: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/26.jpg)
Monitoring Fluid balance
important in heart, renal, liver patients where fluid restrictions may be needed
input and output
daily in acute setting- fluid balance charts
compare feed/fluid volume given with feed prescribed
Weight assess changes on hydration and body composition over time under/over feeding fluid shifts / changes in hydration weekly/twice weekly when starting or if hydration concerns monthly for an established home enteral feed
![Page 27: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/27.jpg)
Monitoring
Clinical condition of patient
ensure feed tolerated
feeding route remain appropriate
changes in treatments
changes in lifestyle
![Page 28: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/28.jpg)
Enteral to Oral Intake
50% of calorie requirements orally + 2 x high protein supplements
SLT
Food charts really important in assessing oral intake
Overnight feeding
Intermittent bolus feeding with oral intake
![Page 29: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/29.jpg)
References Percutaneous endoscopic gastrostomy: indications,
technique, complications and management (World
Jrnl Gastroenterology: 2014 Jun 28:20(24)
ESPEN guidelines of artificial enteral nutrition-PEG:
Clinical Nutrition 2005
BAPEN Website
Guide to Refeeding Syndrome- Southern District
Health Board
![Page 30: Breiga Pepping Clinical Dietitian Dunedin Hospital 1600.pdf · Administration of Formula Bolus feeding PEG / NGT only Gravity / Syringe Push / Pump Bolus usually over 5-6 feeds spread](https://reader030.fdocuments.in/reader030/viewer/2022040120/5e8b08e349c254471a3e9e84/html5/thumbnails/30.jpg)