Chapter 5 - Enteral & Parental Nutrition Support

what percentage of hospitalized patients are malnutritioned?

40%

what percentage of patients living in nursing homes are malnutritioned?

90%

what percentage of patients that are hospitalized will decline nutritionally? what amount will become malnourished?

50%

1/3

healthcare cost and utilization project (HCUP)

analyzed U.S. hospitalizations that involved a diagnosis of malnutrition

consequences of inadequate nutrition and subsequent malnutrition

increased risk of infection

delayed wound healing

higher risk of 30-day admission rates

longer length of hospital stay

delayed return to home, work, or baseline activities

greatest contributing factors for malnutrition

older patients

poor appetite

hospital meal refusal

placement in rehab, subacute, or long term care

when did PN support become important

1970s

when did successful PN begin

1937 when it was reported that you could “feed” a pt using IV dextrose and protein hydrolysate solutions.

protein and kcal were hard to provide

what doctors perfected technique in beagle puppies that allowed hypertonic dextrose and protein solutions to be administered through a central vein

Dr. Stanley Dudrick and Dr. Douglas Wilmore built on work of Dr. Rhoads and Dr. Vars

adoption of central vein PN led to development of new parental solutions:

cystalline amino acid solutions and IV fat emulsions

these provide essential fatty acids

nutrition support definition

medical treatment that provides nutrition therapy when there is an inability to obtain adequate nutrition through food alone

nutrition support should be based on:

evidence based medicine incorporating benefit-risk-burden analysis after thorough discussion with the pt and family members

enteral nutrition definition

feeding through the gastrointestinal tract using a tube, catheter, or stoma that delivers nutrients distal to the oral cavity

stoma definition

a surgically created artificial opening made into a hollow organ

the 2016 ASPEN/SCCM critical care guidelines recommend that

“nutrition support therapy in the form of early EN be initiated within 24-48 hours in the critically ill patient who is unable to maintain volitional intake”

first decision in designing EN prescription

establish access to the GI tract. (often determined by the primary physician)

what is evaluated to establish access to GI tract

the access route is often determined by the primary physician according to the patients diagnosis and the anticipated amount of time the patient will require support.

(disease state, aspiration risk, GI anatomy, gastric and intestinal function, estimate length of therapy)

nasogastric

a tube that is inserted nasally (through the nose) into the stomach

orogastric feeding tube

a tube that is inserted orally (through the mouth) into the stomach

type of feeding access is described according to:

1. where the tube enters the body

2. where the tip is located

why is nasogastric the most common

easiest to achieve

easiest to maintain

least expensive

acceptable in most clinical situations

nasoenteric feeding tubes

enter the GI tract through the nose and reside in the duodenum or jejunum

enteral nutrition is also called

tube feeding or enteral feeding

postpyloric access is used…

used to bypass the stomach in cases of gastroparesis or gastric outlet obstruction

benefit of postpyloric feeding

minimize accidental aspiration of formula

disadvantage of nasogastric and nasoenteri feeding tubes

discomfort for the patient

nasal tubes are easily dislodged and may have to be replaced frequently

what tubes are typically used for short term therapy

tubes through the nose or mouth

infants will have an orogastric tube placed under the following conditions:

<34 weeks gestation with gag reflex

basilar skull fractures

respiratory distress

requirement for oxygen

nasal trauma

if orogastric tubes for infant isn’t an option…

decisions for tube placement in infants follow same guidelines as for adults

when the RDN is responsible for insertion of nasogastric or nasoenteric feeding tubes…

66% reduction of hospital costs associated with tube insertion

shorter time for insertion and feeding

ostomy

an artificial opening created by surgical procedure

gastrostomy

a tube delivering feedings to the stomach

jejunostomy

a tube delivering feedings through the abdominal wall to the jejunum

how are permanent feeing tubes placed

a physician places feeding tubes while the pt is sedated.

surgical gastrostomy

when a surgeon performs the procedure to place a permanent feeding tube

percutaneous endoscopic gastrostomy (PEG)

when feeding tubes can be placed through the skin without a surgical incision with the use of an endoscope

who is responsible for percutaneous endoscopic gastrostomy (PEG)

a gastroenterologist

“button” gastrostomy

the type of tube lies flush the the abdomen. the lower portion is the balloon that would be inflated to secure placement.

nasogastric indication

normal GI function

nasogastric advantages

• uses and stimulates normal digestive function

• flexibility in administration

• medications can be places

• tube insertion at bedside

nasogastric disadvantages

• aspiration

• discomfort for patient

• nasal irritation

• tube displacement

nasoduodenal indication

normal small intestine function, need to bypass stomach as a primary site of feeding

nasoduodenal advantages

• tube insertion at bedside

• uses and stimulates normal digestive function

• flexibility in administration

• medications can be placed in tube

nasoduodenal disadvantages

• discomfort for pt

• tube displacement

• requires pump or gravity administration

nasojejunal indication

normal small intestine function, need to bypass stomach as primary site of feeding

nasojejunal advantages

• tube insertion at bedside

• uses and stimulates normal digestive function

• flexibility in administration

• medications can be placed in tube

nasojejunal disadvantages

• discomfort for patient

• tube displacement

• requires pump or gravity administration

orogastric indication

normal GI function but need to avoid nasal placement; use with nasal injury, premature infant, nasal prong oxygen

orogastric advantages

• tube insertion at bedside

• uses and stimulates normal digestive function

• flexibility in administration

• medications can be placed in tube

orogastric disadvantages

• aspiration

• discomfort for patient

• tube displacement

gastrostomy indications

normal GI function but need to bypass mouth/esophagus or supplement oral feeding; longer-term feeding access

gastrostomy advantages

• longer term feeding access

• reduced risk of tube displacement

• allows for bolus feeding

gastrostomy disadvantages

• surgical procedure

• risk of irritation and infection at insertion site

PEG indication

normal GI function but need to bypass mouth/esophagus or supplement oral feeding; longer-term feeding access

PEG advantages

outpatient procedure without risk of anesthesia; longer-term feeding access; less expensive than surgical insertion; reduced risk of tube displacement allows for bolus feedings

PEG disadvantages

risk of irritation and infection at insertion site

jejunostomy indication

normal GI function but need to bypass components of GI tract; longer-term feeding access

jejustomy advantages

improved tolerance for early initiation of enteral feeding

jejunostomy disadvantages

• surgical procedure

• risk of irritation and infection for insertion site

• with smaller lumen of tube, the risk of clogging may be greater

• requires pump or gravity administration

initiation and advancement of enteral feeding is based on

• clinical judgement

• established institutional protocols

• current evidence-based guidelines

in a pediatric patients, it is recommended to initiate feeding as soon as

the pt is hemodynamically stable

progression is determined by

tolerance

the goal it to meet _% to _% of estimated needs on day one of enteral support

25-50%

feedings should reach __% of estimated needs within 24-48 hours of initiation

80%

enteral feedings should be initiated within the first

24-48 hours of admission

a concern about enteral feeding prescriptions

a patient does not receive the prescribed formula rate due to the interruptions of feeding for testing or intolerance

volume based feeding definition

a method for delivering EN that allows nursing staff to adjust the volume of EN being delivered to meet a volume target for a 24-hour period

volume based feeding protocols in critically ill patients was associated with….

improved calories and protein delivery and shorter ICU stay

an alternative for volume-based feeding protocols is…

adjusting the infuse rate to account for time in which the EN is being held throughout the day

bolus feedings

consist of the administration of 250-500mL of formula several times a day.

a syringe may be used

intermittent feedings

administration of formula several times a day, over 20-30 minutes.

a pump is typically used to control the flow rate

continuous feedings

administration of formula for 10-24 hours daily, using a pump or gravity to control the feeding rate

what feeding method is preferred in the acute care setting and why

continuous feeding because GI tolerance is maximized. also less time consuming for staff.

disadvantage of continuous feeding

expense of the pump and the disposable equipment that is required for home use.

restricted mobility for the patient

current clinical pracvtice recommends initiation all adult formulas at full strength at…

10-40mL/h and advancing to goal rates by 10-20mL/h every 6-8 hours

the outer lumen diameter is described using a measurement called

french size

1Fr =

.33mm

tubes range from (french size)

10-14Fr

enteral formulas can be provided in

cans or in prepackaged sealed containers

EN is most often delivered using

small pump similar to those used to control intravenous (IV) fluids

steps in determining the nutrition prescription

1. establish dosing weight, protein, energy, and fluid requirement

2. identify an appropriate enteral formula that is consistent with the pts nutritional needs, digestive and absorptive capability, and diagnosis

3. calculate the total energy needs and divide by caloric density of the formula (kcal/mL)

4. divide the total volume by the total number of hours over which formula will be administered (goal rate)

5. determine initial starting rate and recommendations for advancement

what is step 1 of determining the nutrition prescription

establish dosing weight, protein, energy, and fluid requirements

what is step 2 of determining the nutrition prescription

identify an appropriate enteral formula that is consistent with the pts nutritional needs, digestive and absorptive capability, and diagnosis

what is step 3 of determining the nutrition prescription

calculate the total energy needs and divide by the caloric density of the formula (kcal/mL)

what is step 4 of determining the nutrition prescription

divide the total volume by the total number of hours over which formula will be administered. this is the goal rate

what is step 5 of determining the nutrition prescription

determine the initial starting rate and recommendations for advancement

parental nutrition

administration of nutrition directly into the circulatory system

peripheral parenteral nutrition (PPN)

administration of nutrition into a small vein in the arm or back of the hand

central parenteral nutrition (CPN)

terminology supported by ASPEN to replace TPN.

nutrient admixture containing either

• lipid, dextrose, and amino acids (3 in1) or

• dextrose and amino acids (2 in 1)

hyperalimentation

overfeeding patients

PPN

administration of large volume, dilute solutions into a small vein in the arm or back of hand.

prescribed for short term use.

vascular access device (VAD)

a device inserted into a vein, which permits administration of intermittent or continuous infusion of parenteral solutions of medications

osmolality of PPN solution should be…

confirmed to be <900mOsm/L prior to administration through a peripheral line

why is osmolality important to watch in PPN

high osmolality may cause small veins to collapse

what is osmolality

total number of dissolved chemical particles pr kg of solvent (water)

supplemental PN (SPN)

reserved for the patient who is unable to achieve goal calories and protein on EN.

can be provided through a CVC or peripheral line

when should SPN be considered

for those on EN and unable to meet their nutritional needs after one week of an ICU admission

feeding into the venous system through a large-diameter vein allows for

use of high-osmolality solutions of >900mOsm/L which allows delivery of 100% of estimated nutrition requirements

lumen of the catheter refers to

the interior of the tube through which the PN solution passes

the number of lumens should correspond to the

number of therapies the patient is requiring and the drug compatibility with the PN solution