SUPPLEMENTAL NUTRITION. PROS, CONS, AND CHALLENGES. Sue Kane, SA-C, Clinical Coordinator Applied Medical Technology, Inc. Malnutrition. As a general rule, enteral or parenteral feeding is advised when a patient is unable to eat for 7-14 days or longer.
PROS, CONS, AND CHALLENGES
Sue Kane, SA-C, Clinical Coordinator
Applied Medical Technology, Inc.
As a general rule, enteral or parenteral feeding is advised when a patient is unable to eat for 7-14 days or longer.
Malnutrition is a common problem increasing morbidity and mortality of hospitalized patients and is often not recognized throughout the hospital stay. This may affect recovery from illness, surgery and trauma and can result in poor post operative results as well as wound healing and post operative complications.
Usually caused by inadequate nutrient intake in conjunction with a stress response
Chronic diarrhea, renal dysfunction, infection, hemorrhage, trauma, burns, critical illness
Marked hypoalbuminemia, anemia, edema, muscle atrophy, delayed wound healing, impaired immunocompetence
Typically in the emaciated, elderly and chronically ill patient
Weight loss, reduced basal metabolism, depletion of subcutaneous fat and tissue turgor, bradycardia, hypothermia
The gastrointestinal (GI) tract is the route by which the body is supplied with water, electrolytes, and nutrients
There are many clinical conditions in which the GI tract is temporarily or permanently unavailable, not functioning, or damaged. In these situations, the patient’s health is seriously jeopardized. Accessing the GI tract can be done intravenously or by tube feeding. Tubes; nasogastric (NG), nasojejunal (NJ), gastrostomy (G-tube), jejunal (J-tube), and gastrojejunal (GJ-tube) are used to provide the body with nutrition, perform gastric decompression, and to evaluate/treat GI bleeding. Each of these tubes has a specific insertion technique, specific advantages and disadvantages, and complications. This presentation will provide a basic review of the anatomy and function of the GI tract and discuss the use of gastric tubes for enteral nutrition. Specific radiologic techniques that are used for insertion will be discussed and described.
*In the setting of a functional gut, enteral feeding is preferred to parenteral options.
Many clinicians believe that enteral nutrition delivered to the small bowel is a better choice than feedings delivered to the stomach, and will place a NJ feeding tube. This type of feeding tube is more difficult to place than a NG tube, but its proponent’s say that it decreases the risk of aspiration, may provide more calories, and the feeding schedule will be subject to fewer interruptions. Both the jejunum and the stomach can be safely used to deliver calories, the differences between the two types of tubes are minimal, both can be effective, and the decision as to which one to use depends on the skill of the practitioner and the potential tolerance of the patient.
The NJ tube can be placed using an endoscope or by using fluoroscopy. When choosing fluoroscopy the practitioner must weigh the exposure to radiation, the need for transport to the radiology department, patient safety, and cost. Some practitioners have reported success by placing the NJ tube in the stomach and allowing it to spontaneously move into the small bowel. Magnetically guided tubes have also been used as well such as the Cortrak System.
The incidence of accidental loss is high particularly in the critically ill who often have altered levels of consciousness.
Frequent tube dislodgement may prevent effective enteral feeding.
In a prospective study, 21 patients received NG feeding over 173 days. Only 46% of volume feed prescribed was delivered. Each patient required between 2-11 tubes and 85.9% dislodgements were due to patient removal.
Less than half of EN patients achieve their caloric goal
*Prospective audit Leeds Teaching Hospitals NHS Trust/Faculty of Health,Leeds Metropolitan University, Leeds, UK Nov. 2008
Disadvantages: Skin breakdown, uncomfortable, risk of nasal injury
Disadvantages: Uncomfortable, potential damage to nasal septum if pulled by patient or clinician
Disadvantages: Uncomfortable to place, difficult to place, securing tube is challenging
A New Method
The AMT Bridle is an umbilical tape system placed with magnets that attract in the nasopharyx to deliver the umbilical tape through the nares. The NG tube is then secure with the umbilical tape in an appropriate size clip.
An Old Method
A red rubber catheter, usually an 8fr, was placed through the nares on each side, retrieved in the nasopharynx with forceps, tied together, advanced, and then tied around the NG tube.
“Routine Bridling of Nasojejunal tubes is a safe and effective method of reducing dislodgement in the ICU. This simple practice can be performed with low morbidity and may improve enteral nutrition and reduce exposure to procedural complications.”
Christopher W. Seder, MD; Randy Janczyk, MD: NCP Nutrition in Clinical Practice 2008-2009; 23 (6) 651-654
“Nasal bridling decreases feeding tube dislodgement and may increase caloric intake in the surgical intensive care unit: A randomized, controlled trial.”
Christopher W. Seder, MD; William Stockdale, RN; Linda Hale, RN; Randy J. Janczyk, MD, FACS : Critical Care Medicine 2010, Vol. 38 No.3
"Use of Nasal Bridle Prevents Accidental Nasoenteral Feeding Tube Removal.”
Scott R. Gunn, MD, Barbara J. Early, RN; Mazen S. Zenati, MD, MPH, PhD; Juan Ochoa, MD, FACS: JPEN Journal of Parenteral and Enteral Nutrition 2009; 33(1):50-54
Routine flushing with warm water can prevent clogging of feeding tubes.
Acidic products can cause proteins in formula to coagulate. You may need to flush before and after administering solutions.
As an alternative, pancreatic enzymes with sodium bicarbonate may be used. Check with physician.
Push or pull method using an endoscope under local anesthesia and conscious sedation
It is a safer and more cost effective method than surgical placed gastrostomies and has a lower mortality rate
May be replaced with low profile device usually after 6 weeks
A Jejunostomy tube provides nutritional support with the tube placed directly through the abdominal wall into the jejunum. It is particularly useful in patients who are at high risk of aspiration of feedings delivered to the stomach, patients with non-functional stomachs, patients with esophageal carcinoma or chronic pancreatitis, and patients who have had a total gastrectomy.
When gastroesophageal reflux is present there is a high risk of aspiration of gastric secretions and enteral feeding. In this case a G-J tube is used to aspirate gastric contents and feed into the jejunum.
The G-J tube is placed into the stomach and secured by a balloon. There is an extension of the tube with holes that is guided into the jejunum for feeding. There are two ports located on the outside of the tube.
Using a team approach, it is important to start enteral feeding as early as possible. Providing early feeding will result in the best outcome for malnourished and critically ill patients resulting in shorter hospital stays and improving their overall health. Review patient goals daily and use recommended interventions to avoid complications.