HTHSCI 3BB3 - F2023 - 13A - Enteral and Parenteral Nutrition

Undernutrition

includes wasting (low weight-for-height),stunting (low height-for-age) and underweight (low weight-for-age)

micronutrient-related malnutrition

- includes micronutrientdeficiencies (a lack of important vitamins and minerals) ormicronutrient excess (toxicity)

overweight, obesity and diet-related noncommunicabledisease

(such as heart disease, stroke, diabetes and somecancers)WHO, 2021

Malnutrition is associated with increased risk of

morbidity in acute and chronic diseases

• infections

• post-op complications

• mortality

• pressure wound ulcers

Malnutrition is associated with

Poor wound healing• Delayed functional improvement• Increased length of stay• Increased readmission rates• Delay in the initiation of adjunctive treatment

42% of the patients admitted to acute care (medical and surgical wards) are:

moderately or severely malnourished

Malnourished patients receiving nutritional support,compared with those not receiving nutritional support, had:

- a lower in-hospital mortality rate (2525 of 34 967 patientsdied [7.2%] vs 3072 of 34 967 patients died [8.8%]

• a reduced 30-day readmission rate

4 basic "Nursing Admission" questions that are integral to the early identification of nutritional risk patients (in order of importance):

1. Have you lost weight?

2. If Yes, How much weight have you lost and overwhat time frame?

3. What is your current weight?

4. What is your height?

In developed countries the main cause of malnutrition is

The pro-inflammatory effect of illness

Any disease/disorder has the potential to result in or worsen malnutrition

Response to trauma, infection or inflammation may alter metabolism, appetite, absorption or assimilation of nutrients

Organizational Factors

1. Lack of nutrition awareness by healthcareproviders and patients

2. Inappropriate NPO status

3. Multiple medical tests requiring fasted states

4. Unprotected meal times (diagnostics, visitors,transfers) - staff may forget to give food to patient when meal is missed

5. Adverse hospital smells and noises

6. Lack of assistance at meals

7. Food services issues, i.e. unpalatable food, coldfood, selective options, dry and chewy food

8. Lack of nutritious food options outside of meal times

Patient Factors

Illness (Poor appetite• Too sick• Tired• Pain)

Eating difficulties:(Difficulty opening packages / unwrapping food• Uncomfortable position to eat• Difficulty reaching food• Difficulty chewing and swallowing food)

Goals of Clinical Nutrition Intervention

To improve clinical status and outcome

• To restore/improve nutritional status in the face of diseaseand injury

• To possibly modulate/attenuate the disease process• To minimize the catastrophic effects of injury, sepsis and inflammation

• Minimize the rate of lean body mass catabolism and weight loss and work towards anabolism

• Provide essential nutrients (macro and micronutrients)

• Decrease infectious and non-infectious complications

• Reduce length of stay, costs

• Improve quality of life

Oral Nutrititon Indications

- Consistent with medical and patient's goals

• Inadequate oral intake to meet nutrient needs

• Functional gastrointestinal tract (digestion and absorption)

• Safe functional swallow

Oral supplements

- Oral Nutrition Supplements reduced length of stay, episode cost and 30-day re-admission rates

• Length of stay - 2.3 day reduction

• Costs - $4,734 reduction

• Re-admission rates - 2.3% reduction

Enteral Nutrition Indications

- Consistent with medical and patient goals

• Oral intake is deemed unsafe,inadequate, or impossible to meet nutrient needs

• Functional gastrointestinal tract (digestion and absorption)

• Accessible gastrointestinaltract

Enteral Nutrition Contraindications

- Non-operative mechanical GI obstruction

• Intractable vomiting/diarrhea

• Paralytic ileus

• Severe GI bleed

• Perforation of the GI tract

• Inability to gain access to the GI tract

• Aggressive intervention not warranted or not desired "If the GUT works, use it!"

Conditions that may require Enteral Nutritional Support

- Intubation, facial or esophageal trauma, Cerebrovascular accident (stroke)

- Impaired ingestion• A condition (hyperemesis of pregnancy, anorexia associated with CHF, A hyper-catabolic state: Bone Marrow Transplant, severe burns, sepsis)

- Inability to consume adequate nutrition (Pancreatic cancer, short bowel, pancreatitis, gastroparesis)

- Severe wasting/malnutrition (End stage liver disease awaiting transplant, severe Crohn's disease)

Enteral Nutrition Benefits

- Preserves GI tract integrity and function

• Reduce infectious and non-infectious complications associated with disease and injury

• Less expensive than parenteral nutrition• Generally safer than parenteral nutrition

Nasoenteric feeding route

- Nasogastric (NG), nasoduodenal (ND), nasojejunal (NJ)

- Short-term (<3-4 weeks)

Percutaneous enterostomy

- Gastrostomy (PEG) or jejunostomy (PEJ)

• Long-term (>4 weeks)

• Jejunal feeding is indicated when gastric feeding is not possible or tolerated• e.g. aspiration, gastroparesis, abdominal surgery

When thinking about the formula of enteral nutrition, what consideration should be made?

a) Solid foods would be preferred to maintain gut function

b) The patients' condition will impact the composition of the formula

c) Standard formulas can be used in all situation

d) Food allergies are not as important because chewing is not occurring

b) The patients' condition will impact the composition of the formula

Standard or Polymeric Formula

enteral formulas that contain mostly intact proteins and polysaccharides

Elemental or Semi-elemental formula

limited digestive capacity, deliver to duodenum or jejunum, hydrolyzed proteins, low in fat or primarily MCT, high cost, unpalatable

Vivonex, Pivot 1.5

Disease-Specific formula

Formulations developed for specific diseases (e.g. renal orhepatic disease, T2DM

Medication Delivery - oral

some medications require stomach acid to be activated• Medications may interact with the formula and can't be mixed•

Potential Complications of Enteral Nutrition

- aspiration

- vomiting

- increased abdominal distension

- constipation and diarrhea

- metabolic

- tube related issues

Parental Nutrition Indications

Consistent with medical and patient goals

• Patients are unable to meet nutrition needs with Enteral Nutrition

• Pre-operative support in the severely malnourished patient

• Gastrointestinal incompetence (paralytic ileus, small or large bowel obstruction, unlikely to resolve within 5 to 7 days, severe diarrhea with evidence of malabsorption, intractable vomiting)

Parental Nutrition Contraindications

Functional and usable GI tract

• Prognosis does not warrant aggressive nutrition support

• Aggressive nutrition support is not wanted by patient or guardian

• Risks judged to be greater than benefits

TPN indications

- Ileus after major intra-abdominal surgery with no enteral access• Hyperemesis gravidarum when jejunal feedings are unsuccessful

• Severely malnourished patients prior to and during an intensive medical or surgical intervention which precludes the use of the GI tract for at least seven days.

• Patients undergoing high-dose chemotherapy, radiation and or bone marrow transplantation when enteral feeding is unsuccessful.

• Severe acute pancreatitis where enteral feeding is unsuccessful

• Pre-operative support in the severely malnourished patient

Supplemental Parenteral Nutrition

TPN initiated when goal rate feeds cannot be achieved within 48-72 hours• TPN initiated on admission during diagnostic work up

peripheral parenteral nutrition (PPN)

Given through a peripheral vein

• Peripherally Inserted Central Catheter (PICC)

• Short term use - 7 days

• Restrictions: often unable to meet caloric needs

• Site rotation every 3-5 days

• Principle complication -thrombophlebitis

Central Parenteral Nutrition (cpn)

Infused into large central vein

• PORT (Greater percentage of caloric and protein needs)

• Pharmacy compounds the solutions under a septic conditions to prevent bacterial contamination

PN complications

Technical:• pneumothorax, hemothorax, nerve injury,subcutaneous emphysema

• Mechanical:• occlusion or fibrin sheath• thrombus

• Infections

• Metabolic:: Refeeding Syndrome• HYPERGLYCEMIA (hypoglycemia less common, but can occur), electrolyte, mineral abnormalities• hepatobiliary complications• metabolic bone disease

What the RD does before initiating TPN?

- Nutritional Assessment

• Venous access evaluation

• Baseline weight

• Baseline lab investigations

What RNs do once TPN is initiated?

Monitors vital signs, temperature, ins and outs

• Check blood glucose

• Inspect catheter site for signs of inflammation,infection or bleeding and placement

• Visually checks the solution/label (name, ID,expiry date, solution matches prescription, routeof administration, leakage, emulsion stability)

• Maintain aseptic techniques with all procedures related to the setup and administration of TPN and catheter care (site, flushing, hub)

• Ensures that the TPN is delivered at the prescribed rate• Monitor catheters infusion ability "stiff flush"

• Changes IV q 24 hrs. and with each administration of intermittent PN infusions

• Discards solution if it has not been used for >4hours• Checks drug compatibility

What could happen if nutrition is introduce too rapidly in a malnourished individual?

a) Fluid and electrolyte imbalances

b) Excessive weight gain

c) Loss of nitrogen balance

d) Loss of energy balance

Refeeding syndrome

Rapid nutritional repletion in severely malnourished patients

• Characterized by fluid and electrolyte disturbances: hypernatremia, hypophosphatemia, hypokalemia and hypomagnesemia

• Can lead to fluid retention, heart and respiratory failure

• Symptoms: edema, cardiac arrhythmias,muscle weakness, confusion

• Monitor glucose, electrolytes, PO4 and Mg for 3 days

• Low serum levels must be corrected prior to feeding

• Feeds are advanced slowly to preventrefeeding syndrome

Stopping TPN

Wean TPN based on oral diet/initiation of enteral feeding

• In hospital: ½ rate TPN, TPN stopped when patient meeting~50-60% of estimated requirements via EN or oral intake

• At home: Decrease total calories/day or decrease number of nights infuse