Basics of enteral and parenteral nutrition
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Basics of enteral and parenteral nutrition. Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training. Objectives. To discuss the different feeding pathways for the surgical patients

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Basics of enteral and parenteral nutrition

Basics of enteral and parenteral nutrition

Surgical Nutrition Training Module

Level 1

Philippine Society of General Surgeons

Committee on Surgical Training


Objectives
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 Pathways

Can the GIT be used?

“Inability to use the GIT”

Yes

No

“inadequate intake”

Parenteral nutrition

Oral

Tube feed

< 75% intake

Short term

Long term

More than 3-4 weeks

Central PN

Peripheral PN

Yes

No

NGT

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.

Gastrostomy

Nasoduodenal or nasojejunal

Jejunostomy



Early enteral nutrition definition
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
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
Early enteral feeding: goal

  • To maintain intestinal mucosal integrity

    – Normal microvilli

    • Height and number

      – Normal intestinal barrier

      – Intestinal mucosal immunity


Early enteral feeding rationale
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: mortality

Heyland et al. JAMA, 2001

Outcome: early enteral nutrition vs. control

Treatment n/N

Control

n/N

Study

1/11

1/9

Cerra et al 1990

2/17

1/14

Gottschlich et al, 1990

0/19

Brown et al, 1994

0/18

1/51

Moore et al, 1994

2/47

24/163

12/143

Bower et al, 1996

1/16

Kudsk et al, 1996

1/17

20/87

Ross Products, 1996

8/83

7/18

Engel et al, 1997

5/18

1/22

Mendez et al, 1997

1/21

2/16

Rodrigo et al, 1997

2/13

2/16

Weimann et al, 1998

4/13

96/197

86/193

Atkinson et al, 1998

17/89

Galban et al, 2000

28/87

Pooled Risk Ratio

0.01

0.1

1

10

100

Higher for control

Higher for treatment

Early enteral nutrition vs standard nutritional support on mortality



Enteral nutrition access

JEJUNUM

STOMACH

Nasojejunal tube

Nasogastric tube

PEJ

PEG

BUTTON

JET-PEG

PLG

PLJ

Witzel, Stamm, Janeway

NCJ

PSJ

PSG

PFJ

PFG

E: Endoscopic

G: Gastrostomy

J: Jejunostomy

Loser C et al. ESPEN guidelines on artificial enteral nutrition – Percutaneous endoscopic gastrostomy (PEG)

L: Laparoscopic

NC: Needle Catheter

S: Sonographic

F: Fluoroscopic

Enteral nutrition access


Access and delivery

Nasogastric tube

Nasoentericor jejunal tube

PEG tube

Access and delivery


Gastrostomy
Gastrostomy

PEG placement

PEG placement,

St Luke’s Medical Center


Post pyloric feeding

Long Term (operative)

Jejunostomy

– Percutaneous endoscopic jejunostomy or through the PEG tube

– Surgical jejunostomy

Short Term

Nasoenteric

– Nasoduodenal

– Nasojejunal

Post-pyloric feeding

Gauderer MW, et al. J Pediatr Surg 1980;15:872-875


Enteral formulas what type
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
Enteral nutrition delivery

Gravity Feeding

Enteral Pump Delivered


Practical points enteral nutrition
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 nutrition1
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
    Enteral formula: commercial vs. blenderized

    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



    Standard feed measured vs expected
    Standard Feed: measured vs. expected

    Commercial formula

    Natural food formula

    Commercial formula

    Natural food formula

    Sullivan MM et al. Nutritional analysis of blenderized diets in the Philippines (PENSA 1998)


    Monitoring gastric residuals
    Monitoring Gastric Residuals

    • 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



    Parenteral nutrition indications
    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.


    Contraindications to pn
    Contraindications to PN

    • 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.

    .* 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
    Types of parenteral nutrition

    Central

    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

    • 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


    Types of parenteral nutrition1
    Types of parenteral nutrition

    • Central parenteral nutrition

    • Peripheral central parenteral nutrition

    PICC =peripherally inserted

    central catheter


    Catheters
    Catheters

    Subclavian catheter (3 ports)

    PICC line catheters


    Types of parenteral nutrition2
    Types of parenteral nutrition

    • Peripheral parenteral nutrition


    Central venous access
    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
    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”

    Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382.

    Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2nd ed 2005; 97-107.


    Formulation delivery
    Formulation / Delivery

    Development phases of the PN container system

    Individualized

    delivery system

    Compounding / clean

    rooms

    Break seal

    • cheaper

    • stable

    • none to minimum contamination

    “All in one” placed in

    multi-chambered bags


    Safety issues
    Safety issues

    • In-lineFilters:

    • Fat emulsions

    • Three in one solutions

    • Micro-precipitates

    • Protocols:

    • Compounding

    • Incorporation – additives

    • Delivery (access, rates of infusion, infusion pumps)

    Three in one bags: longer storage and less contamination


    En pn monitoring parameters
    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
    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 week

    Jan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003


    Outcome is dependent on the monitoring process
    Outcome is dependent on the monitoring process


    Feeding Pathways

    Can the GIT be used?

    “Inability to use the GIT”

    Yes

    No

    “inadequate intake”

    Parenteral nutrition

    Oral

    Tube feed

    < 75% intake

    Short term

    Long term

    More than 3-4 weeks

    Central PN

    Peripheral PN

    Yes

    No

    NGT

    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.

    Gastrostomy

    Nasoduodenal or nasojejunal

    Jejunostomy






    Adequate intake in surgery patients
    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
    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)



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