Clinical Nutrition 3

B|BRAUNClinNutr3/ OPM Germany/Stand 02

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. Basic Care . Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care .

Stoma Care . Wound Care .

Enteral Nutrition

Clinical Nutrition 3

Enteral Nutrition


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Enteral Nutrition

The patient

Indications for Enteral Nutrition

• is not able• is not allowed

• refuses

to eat

to eat

to eat


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Enteral Nutrition

Indications of Enteral Nutrition

• mechanical obstructions• inadequate food-intake

• maldigestion / malabsorption• inflammatory processes• neurogenic disorders

• trauma / sepsis• drug / radiation therapy• chronic diseases

• preoperative and postoperative conditions

Indications


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Enteral Nutrition

Indication: Maldigestion

Insufficiency of the exocrine pancreas

chronic pancreatitis pancreatic cancer pancreatic resection mucoviscidosis (= cystic fibrosis)

Lack of bile acid

reduced production advanced hepatic cirrhosis flow impairments: stenosis, gallstones, tumor

Lack of intestinal digestive enzymes

lactase other disaccharidases peptidases


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Enteral Nutrition

Indication: Malabsorption

Malabsorption

intestinal resection

Crohn´s disease/ulcerative colitis

diarrhea

disturbed intestinal perfusion

disturbed lymph flow

drugs

• sprue = celiac disease


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Enteral Nutrition

Contraindications

absolute contraindications relative contraindications

• shock of any genesis

• metabolic disorders

• acute abdomen

- acute gastrointestinal bleeding

- mechanical ileus

• acute pancreatitis

• paralytic ileus (minimal nutrition possible)

• high reflux-rate (minimal nutrition possible)

• uncontrolled vomiting

• persisting diarrhea

- acute metabolic acidosis

- acute serious hypoxia

- acute serious respiratory insufficiency


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Enteral Nutrition

Dietary Foods for Special Medical Purposes (FSMP)

Nutritionally Complete diet

suitable as sole source of nourishment

Nutritionally incomplete diet

specific for a disease

not suitable as the sole source of nourishment

Nutrient-defined diet (NDD)

diet containing main nutrients (carbohydrates, fats, proteins) in their naturally occuring form

Chemically-defined diet (CDD)

diet containing main nutrients completely or partly hydrolyzed

Standard nutrient formulations or nutrient-adapted formulations for exclusive or partial feeding (1999/21/EG)


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Enteral Nutrition

Characteristics of FSMP

• energy density (kcal/mL)

• energy ratio (protein : fat : carbohydrates)

• balance of minerals, trace elements and vitamines• standard nutrient formulation or nutrient-adapted formulation specific for a disease • defined source of raw materials

„Category of foods for particular nutritional uses specially processed formulated and intended for the dietary management of patients and to be used under medical supervision.“ (1999/21/EG)


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Enteral Nutrition

Osmolarity: mOsm/L

= number of osmotically active particles per liter solution

(point of reference: volume)

Osmolality: mOsm/kg

= number of osmotically active particles per kg solution (point of reference: weight)

Osmolality of blood plasma: 285-295 mOsm/kg

Osmolarity Osmolality


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Enteral Nutrition

• dietary ratio corresponding to the recommendations

Standard Diets

• high-molecular / high-polymeric (NDD)

• with / without dietary fibers

• close to physiologic osmolarity

adequate for patients with normal digestion and metabolism


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Enteral Nutrition

Disease Specific Diets

indication modification

defined combination of fatty acids (relation of 3 : 6 : 9 fatty acids)

high caloric

starch, glucose substitutes, partly fat modified, rich in dietary fibers

high energy need, fluid restriction

diabetes mellitus

respiratory insufficiency, stress metabolism

maldigestion, malabsorption hepatic insufficiency, stress metabolism

high lipid formulations

MCT content

impaired immune functions


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Enteral Nutrition

Disease Specific Diets

indication modification

protein rich

low protein

addition of branched chain amino acids

hepatic insufficiency

high glutamine content

addition of arginine and RNA

protein malnutrition, catabolism

nephrology, pediatrics

special nutrition forfast proliferating cells (enterocytes, lymphocytes)

disturbed wound healing,impaired immune functions


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Enteral Nutrition

Advantages of an Early Enteral Nutrition• preserving the functions of the gut associated lymphatic tissue

• maintaining the barrier of the intestinal mucosa

• prevention of villous atrophy by endoluminal substrate induction and

improved perfusion in the splanchnic area

• reduction of the pathological bacterial flora

• improved prophylaxis against infections and sepsis

• improved wound healing

• stimulation of gastrointestinal hormones

• early triggering of the intestinal motility

• reduced loss of nitrogen (= loss of muscular tissue = loss of body weight)

• prophylaxis against gastric / intestinal ulcers


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Enteral Nutrition

Prophylaxis of Ulcers by Enteral Nutrition

Gastric stress ulcers are typical intensive care complications

• ulcer prophylaxis by antacids and H2-blocker intestinal bacterial flora overgrowth nosocomial pneumonia

• ulcer prophylaxis by enteral nutrition physiological regulation of acid output stimulation of protective mechanisms continuous administration is more effective than bolus injection

Therapy

• increased gastric acidification

• reduced protective function of the mucosa

Etiology


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Enteral Nutrition

Enteral Routes

• oral

• nasogastral, nasoduodenal, nasojejunal

short-term tube feeding

• percutaneous endoscopically controlled gastrostomy (PEG)

long-term tube feeding

• fine needle catheter-jejunostomy (FNCJ)

postoperative tube feeding


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Enteral Nutrition

Feeding-Tube Positions

Transnasal Feeding Tubes1. nasointestinal feeding tube2. nasogastric feeding tube

Percutaneous Feeding Tubes3. PEG4. PEG with intestinal transfer tube5. button6. PEJ7. FNCJ

1


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Enteral Nutrition

• weak / missing protective reflexes

dysphagia of neurologic genesis

hiatal hernia (displacement of stomach)

reflux esophagitis

Gastric Tube Feeding

Requirements

• adequate protective reflexes

normal gastric emptying

Contraindications


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Enteral Nutrition

Advantages of Gastric Nutrition

gastric reservoir function

tolerance concerning quantity and osmolarity controlled nutrient passage into small intestine

bactericide effects of gastric acid

buffering of gastric acid by food


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Enteral Nutrition

Duodenal / Jejunal Tube Feeding

• obligatory continuous administration (by pump): maximum 150 ml/h

Indications

Requirements

disturbed gastric emptying

gastric resection

reflux

vomiting

early postoperative diet

• endoscopic or radiological position control


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Enteral Nutrition

Diameter and Length of Feeding Tubes

out-side diameter 5 – 32 FR (1 F =1/3 mm)

most frequently used: 8 – 15 FR

the smaller the diameter, the more convenient for the patient (function of the esophageal sphincter remains preserved)

in case of gravity administration 12 FR

8 FR mostly in case of pump administration

40 -250 cm length, with marks for x-ray control of position

F = French (or Charriere)


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Enteral Nutrition

Material of Feeding Tube

PVC feeding tubes (polyvinylchloride)

dissolving of the softener, material is becoming hard and cracking decreased function of the esophageal sphincter through

rigid material reflux of stomach contents

• only for short-term use, daily change necessary


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Enteral Nutrition

Material of Feeding Tubes

Silicone feeding tubes

• flexible without softener

• long term placement

• in comparison to PUR feeding tubes: thick tube walls are necessary to guarantee stability,

as a consequence the out-side diameter increases

PUR feeding tubes (polyurethane)

• soft, flexible, no softener• little wall thickness

• long term placement


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Enteral Nutrition

Placement of Feeding Tubes

• local anesthesia of the nose

• introduction as far as pharyngeal space, use of lubricant may be necessary

• support of the esophageal passage by swallowing

• slow introduction into the stomach

• aspirate changes colour of pH-test paper into red (acidic reaction of gastric acid)

• insufflation and ausculation (administration of air into the feeding tube by a syringe) typical feeding tube

• optional: x-ray control

Nasogastral:

Control of position:


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Enteral Nutrition

Placement of Feeding Tubes

• careful transpyloric introduction of feeding tube into the small intestine

• endoscopic placement and control x-ray control

Nasoduodenal:

Position control:

Alternative method:

• seldinger technique (placement over an endoscopically positioned guide wire)


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Enteral Nutrition

PEG Feeding Tubes

Indications

• long-term enteral nutrition in case of– cachexia

– dysphagia– tumors in the head-neck area– multiple trauma– surgery

• gastric decompression and drainage


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Enteral Nutrition

PEG Feeding Tube

• Lack of diaphanoscopy

• general disorders of wound healing and blood coagulation

• peritonitis/peritoneal carcinosis


• pathological alterations of the gastric wall

• ileus

• sepsis

• relative: Crohn´s disease and ascites

• missing agreement of the patient

Contraindications


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Enteral Nutrition

Introduction of PEG („Keymling Method“)

introduction of the gastroscope, air insufflation, determination of the puncture site by diaphanoscopy (fig.1)

disinfection and anesthesia of the puncture site, advance puncture cannula into stomach under endoscopic

control (fig. 2)

removal of the puncture needle, introduction of the thread into plastic cannula (fig. 3)

removal of the guide-thread by endoscope forceps (fig. 3)

fixation of the tube to guide thread by double knot (fig. 4)

retraction of the thread until the silicone disc of the tube stops at inner gastric wall (fig. 5)

fixation of plate, introduction of the clamp and the luer-lock connector (fig.6)


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Enteral Nutrition

Introduction of PEG according to Keymling

diaphanoscopy

puncture

guide thread insertion

double knot fixation

tube placement

external fixation

fig. 1

fig. 2

fig. 3

fig. 4

fig. 5

fig. 6


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Enteral Nutrition

PEG Complications

most common complications:

— local wound infections

— disturbed microcirculation in case of strong tension between inner and outer fixation plate

rare complications: — necrosis and ingrown fixation plate

— peritonitis

— heavy bleeding because of vascular lesion during puncture


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Enteral Nutrition

Wound Dressing for PEG Feeding Tubes

•slit and fleece compresses, fixation fleece

• initially daily change, later once or twice a week

•skin disinfection

•daily rotation of the tube

after ~ 14 days: formation of a stable fibrous channel

• loose fixation of the external fixation plate


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Enteral Nutrition

J-PEG tubes

• placement of a intestinal tube (9 FR) through the already indwelling PEG tube 15 FR

• assumption of the placement of a J-PEG tube– size of the lumen of the placed PEG tube: at least 15 FR

– possibility of the navigation of the intestinal tube through pyloric and duodenal stenoses


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Enteral Nutrition

J-PEG tubes

Indications

• long-term intestinal feeding with simultaneous gastric decompression in patients with

– loss of consciousness

– gastric outflow obstruction

– neurological dysphagia with risk of aspiration

– pyloric and duodenal stenoses which can still be navigated by the intestinal tube

– pancreatitis

– hiatal hernias• enteral nutrition during the early postoperative phase• intestinal recycling of bile with simultaneous gastric feeding


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Enteral Nutrition

J-PEG tubes

• lack of patient consent

• Peritonitis / peritoneal carcinoma

• mechanical Ileus distal to a jejunal tube

• generalized disorders of coagulation

Contraindications


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Enteral Nutrition

• removal of the Luer-Lock connector of the already placed PEG tube. Fixation of the Y-adapter (fig. 1 / 2)

• placement of the intestinal tube via the intestinal leg („i“, green) (fig. 3)

• Shortening of the intestinal tube and connection with the positive/negative Luer-Lock connector (fig. 4)

• Connection of the tube with the Y-adapter of the PEG tube (fig. 4)

• radiological checking of the tube position (or sonographic)

Introduction of the J-PEG


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Enteral Nutrition

Introduction of the J-PEG


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Enteral Nutrition

complications of the J-PEG tube

• most comon complications: - dislocation of the intestinal tube

- gastric loop formation

- local wound infections related to the PEG

further complications cf. PEG tube


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Enteral Nutrition

Fine Needle-Catheter Jejunostomy (FNCJ)

Indications

• postoperative enteral nutrition:– after open gastrointestinal surgery

– for patients with multiple trauma

• long-term nutrition, if introduction of PEG is impossible


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Enteral Nutrition

Fine needle-catheter jejunostomy (FNCJ)

• chronic and acute inflammation of the small and

large intestine

• mechanical ileus

• peritonitis


• missing aggreement of the patient

Contraindications


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Enteral Nutrition

Introduction of FNCJ

Principle of the method

A fine needle-catheter jejunostomy is carried out during surgical interventions (laparotomy).

• puncture of abdominal wall (fig. 1)

• splitting and withdrawal of puncture needle (fig. 2)

• puncture of jejunum and channeling (fig. 3)

• fixation of tube (fig. 4)


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Enteral Nutrition

Introduction of FNCJ

puncture of abdominal wall

splitting of puncture needle

puncture of jejunum

fixation


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Enteral Nutrition

Ways of Enteral Feeding

bolus fast injection of 250-500 mL

- by syringe

continuous feeding

low flow rates

- by pump

intermittent feeding 200 - 400 mL in 30 - 60 minutes

- by gravity- by pump

nutrient-intake


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Enteral Nutrition

Application Systems

Connection with nutrient container

• administration set with bottle-connection (screw cap / crown cork)

• storage-bag with integrated set

• spike application systems

Connection with feeding tubes:

• luer-lock

• funnel / cone

• luer-plug


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Enteral Nutrition

Application Systems

bottle-connection storage-bag


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Enteral Nutrition

General requirements for a feeding-pump

acoustic und optic alarm in case of

- occlusion

- air in the application system

- end of administration (volume, time)

- low battery capacity

- disorder of the equipment

• small, light and handy• easy handling• easy setting and cleaning• easy introduction of the pump segments• quiet• operation by rechargeable battery• bag for mobile use• easy error analysis


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Enteral Nutrition

Indications for Pump-Controlled Enteral Nutrition

• slow and controlled start of enteral nutrition

• early postoperative feeding

• intestinal administration (obligatory)

• pediatric enteral nutrition

• gastrointestinal complications(disorders of gastric emptying, diarrhea, vomiting, etc.)

• impaired digestion(for example: progressive tumors)

• metabolic disorders (for example: complications in diabetes mellitus)

• prophylaxis of aspiration(individual decision)


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Enteral Nutrition

Patient Monitoring

diagnosis andproblems of

the patient

tube feeding diet and

way of administration

requirements of the patient:- energy, - nutrients, - liquid


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Enteral Nutrition

control: x-ray, aspiration of gastric fluid (pH control), air insufflation

Patient Monitoring

correct tube position

adequate gastric emptying (control of aspirate volume)

adequate protective reflexes

skin and wound control

Start of tube feeding


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Enteral Nutrition

Patient Care

elevated head of the patients bed (30 -45 degrees)

temperature of tube feeding: room temperature

rinsing of the feeding tube before and after feeding and medication

define and control feeding time

daily change of the application systems care of mouth and nose, stimulation of salivary

secretion

correct medication (nutrient-drug-interactions)

initially low dose / low rate

change of wound care kits

keeping hygiene standard


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Enteral Nutrition

Liquid Application

• fresh tap water(if quality is adequate)

•mineral water without gas

•black tea

discolouring of the tube

•beverages with gas or fruit acids(for example: coke, juice, fruit tea)

tube clogging, sedimentations, flatulence

adequate inadequate

to cover liquid needs

(taking the liquid-content of food into account)

to rinse the feeding tube

In case of giving tea or preboiled water: do not leave vessel open, cool down covered, use fresh tea / water daily!

!


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Enteral Nutrition

Rinsing of the Tube

Rinse according to the length of the feeding tube by using 40 - 60 ml liquid (use 20 ml syringe)

• before start of tube feeding• in case of interruption• during continuous supply: every 4-8 hours• after termination of tube feeding• before medication• after medication• in case of unused tube: once a day


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Enteral Nutrition

Enteral Medication•Rinse tube thoroughly before and after

each medication

•do not give drugs together with enteral diets

•prefer fluid drugs

•dilute with enough water

•attention to carrier substances

incompatibility

complete dissolving of capsula and tablets

high osmolarity of drugs

diarrhea, electrolyte shifts (example: sorbitol-containing drugs like paracetamol-juice)

!


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Enteral Nutrition

Medication during Tube Feeding

Is oral application possible?

no yes

alternative routes of application: rectal, transdermal, sublingual, subcutaneous, i.m., i.v.

enteral applicaton through feeding tube

(if possible: liquids)

oral application


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Enteral Nutrition

Type and position of feeding tubes are crucial for administration

and effect of the drug.

Medication through Feeding Tubes

• in-side diameter application of the drug

• position of feeding tube diluting processes

• gastric position pH 1,5

• duodenal position pH 8


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Enteral Nutrition

Monitoring of Enteral Medication

serum-level of the drug

clinical effect

effect on the intestinal motility, diarrhea

incompatibility: interaction between drug and tube feeding diet

side effects: e.g. diarrhea


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Enteral Nutrition

Enteral Start-Regime

0

500

1000

1500

2000

2500

1 2 3

tube feeding

liquid

mL

day

Total volume: 2500 mL/day


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Enteral Nutrition

Gastric Emptying

hormone-regulated reflex-mediated (N. Vagus) by chemoreceptors of the small intestine

Fluid-emptying: pressure difference between stomach and duodenum

Particle-emptying: < 2 mm bigger particles are hold back by retropulsion, emptying during interdigestive stage

Regulation:


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Enteral Nutrition

Time of Gastric Emptyinggastric contents

neutral,hypoosmolar,

proteins, carbohydrates

Lipids, hyperosmol

ar,acidic

emptying timehigh

emptying time low


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Enteral Nutrition

Gastric Emptyingtransitory disorders of gastric emptying:

•after surgery / anaesthesia•viral gastroenteritis•hyperglycemia•hypothyreosis

•opiates, anticholinergica, -adrenergic substances, nicotine

chronic retardation of gastric emptying:

• functional dyspepsia• diabetes mellitus• stage after vagotomy• anorexia nervosa• sklerodermia• dermatomyositis• neoplasia of the stomach• idiopathic (as an independent clinical picture)


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Enteral Nutrition

Gastrointestinal Motility after SurgeryBegin of function depends on alimentary stimulation

32-72 hours after surgerystomach

small intestine

8-12 hours after surgery

32-72 hours after surgerycolon


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Enteral Nutrition

aspirate volume after tube feeding< 150 ml > 150 ml

aspirate back into the stomach aspirate back into the stomach continue tube feeding interruption for 1 hour

continue tube feeding

aspirate volume after 2 hours< 150 ml > 150 ml

aspirate back into the stomach 150 ml aspirate into the stomach continue tube feeding interruption for 1 hour

reduce flow rate of supply

new control after 2 hours

Control of gastric emptying after surgery or traumaAspiration of gastric contents


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Enteral Nutrition

Complications in Enteral Nutrition

• mechanical complications

• gastrointestinal complications

• metabolic complications

• infectious complications

Complications:


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Enteral Nutrition

Complications

mechanical• dislocation of the

tube

• obstruction of the tube

• esophagitis

gastrointestinal• diarrhea

• flatulence

• nausea

metabolic

• wound infection

• aspiration pneumonia

• peritonitis

infectious complications

• hyperglycemia• electrolyte shifts• dehydration (= tube feeding syndrome)• overhydration ( heart failure)


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Enteral Nutrition

Aspiration Pneumonia

gastric esophageal reflux of gastric contents into the respiratory tract

• actively by vomiting• passively by regurgitation

Etiology

• reduced or missing protective reflexes and function of gastric sphincter in case of unconscious or anesthetized patients• ileus• gastrointestinal bleeding• high secretion

• increased gastric and intraabdominal pressure because of - disturbed gastric emptying - pregnancy - drugs (succinylcholine) - intraabdominal lesions nasogastric tube as cause of reflux


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Enteral Nutrition

control of protective reflexes

during enteral feeding: elevation of the head of the patient’s bed (30 - 45 degrees)

control of gastric emptying

Aspiration Prophylaxis

!


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Enteral Nutrition

Gastrointestinal Complications - Diarrhea

• food intolerance, allergy

•drugs

• tube feeding diet dietary fibers, MCT-content mono-, disaccharides rate of supply,

concentration

reduction and avoidance of related nutrients

reduction of osmolarity control of side effects

room temperature

control of hygiene standard

• infection

• colon-atrophy

preparations of intestinal bacteria special enteral diets

• chemo-/ radiation therapy flow rate special diets

• temperature of food

(osmolarity of 250 to 500 mOsm/L does not cause diarrhea)

clarification of etiology, iatric intervention


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Enteral Nutrition

Gastrointestinal Complicationsconstipation, flatulence,

diarrhea

control of side effects

increase liquid supply

supply of dietary fibers

reduce flow rate and concentration

adjusting diet to room temperature

control of gastric emptyin (important in case of diabetes mellitus)

in case of intolerance reaction / allergy: reduce or avoid related nutrients

control side effects of drugs, reduce osmolarity

reduce flow rate and concentration

treatment of gastritis and infections

in case of steatorrhea: MCT-rich diet

nausea, vomiting, diarrhea


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Enteral Nutrition

Documentation of Enteral Nutrition

position of feeding tube

skin alterations

quantity and quality of diet (calculated actual

deviation)

administration time / flow rate

feces: quantity, consistency, colour, frequency

urine: quantity, abnormity

drugs

complications

Clinical Nutrition 3

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