LECTURE 6 BASICS OF ENTERAL AND PARENTERAL NUTRITION...

LECTURE 6 – BASICS OF ENTERAL AND PARENTERAL NUTRITION

1

Slide 1

Basics of enteral and parenteral nutrition

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

We now come to the implementation part of the surgical nutrition training module. How do we deliver enteral (EN) and parenteral nutrition (PN) and what are the indications for choosing either EN or PN or both?

Slide 2

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

These are the objectives of this session: • To discuss the different feeding pathways for surgical patients • To define and discuss key points of enteral and parenteral nutrition • To discuss the monitoring process and expected outcomes for surgical patients


2

Slide 3

Feeding PathwaysCan the GIT be used?

Yes No

Parenteral nutritionOral

< 75% intake

Tube feed

Short term Long term

Peripheral PN Central PN

More than 3-4 weeks

No Yes

NGT

Nasoduodenal

or nasojejunal

Gastrostomy

Jejunostomy

“inadequate intake”

“Inability to use the GIT”

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.

We revisit the feeding algorithm which was discussed earlier in session 3 “The impact of nutrition care in surgery”. Here the priority is always the use of the gut (=“If the gut works use it”) and when we fail to deliver 60% to 70% of the patient’s computed intake then that is the only time when we resort to parenteral nutrition. However one has to try always to give some degree of enteral nutrition whenever possible due to the role of the gut in immune function and other related metabolic functions. Slide 4

EARLY ENTERAL NUTRITION

We again re-emphasize the value of early enteral nutrition after surgery or when resuscitation from a critical care state is able to have stable vital signs for the patient.


3

Slide 5

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

Early enteral nutrition is enteral nutrition that is initiated within 24 – 48 hours following hospitalization, trauma, or injury. • Zaloga GP. Crit Care Med 1999; 27: 259


4

Slide 6

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

Why is early enteral nutrition important? These are the major reasons: • The normal and designed route for nutrient intake, digestion, and absorption is the GIT • Immune competence is a major function of the gastrointestinal tract and to sustain this the

gut has to be used continually • Non-utilization of the gastrointestinal tract even on a short term basis leads to complications

in critical care or geriatric patient management secondary due to disuse, atrophy and reduction of function of the gut associated lymphoid tissue system (GALT)

• Cost-effective


5

Slide 7

Early enteral feeding: goal

• To maintain intestinal mucosal integrity

– Normal microvilli

Height and number

– Normal intestinal barrier

– Intestinal mucosal immunity

This is the goal of early enteral feeding: • To sustain the normal height and number of the microvilli • This architecture sustains the normal intestinal barrier by the mucosal epithelium • This set up also sustains intestinal mucosal immunity through the humoral immunity

(=IgA secretion) and cellular immunity (=M cells, mucosal macrophages and T-lymphocytes)


6

Slide 8

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

How does enteral feeding do all of the above?

• By providing nutrients required during metabolic stress

• By maintaining GI integrity

• By reducing morbidity which is higher with patients on long termparenteral nutrition

• By reduce cost compared with parenteral nutrition


7

Slide 9

Early enteral nutrition vs standard nutritional support on mortality

Comparison: mortality

Outcome: early enteral nutrition vs. control

Study Treatment n/N

Control n/N

Cerra et al 1990

Gottschlich et al, 1990

Brown et al, 1994

Moore et al, 1994

Bower et al, 1996

Kudsk et al, 1996

Engel et al, 1997

Weimann et al, 1998

1/11

2/17

0/19

1/51

24/163

1/16

7/18

2/16

1/9

1/14

0/18

2/47

12/143

1/17

5/18

4/13

0.01 0.1 10 100

Higher for control Higher for treatment

Ross Products, 1996 20/87 8/83

Mendez et al, 1997 1/22 1/21

Rodrigo et al, 1997 2/16 2/13

Atkinson et al, 1998 96/197 86/193

Galban et al, 2000 17/89 28/87

Heyland et al. JAMA, 2001

Pooled Risk Ratio

1

This meta-analysis done in 2001 shows the value of early enteral nutrition in reducing mortality in critical care patients compared to the standard NPO for more than three days. • Heyland et al. JAMA, 2001

Slide 10

ENTERAL NUTRITION

What are the access routes of enteral nutrition?


8

Slide 11

Enteral nutrition accessSTOMACH JEJUNUM

Nasogastric tube Nasojejunal tube

PEG PEJ

BUTTON

PLG

JET-PEG

PLJ

NCJ

PSJ

PFJ

PSG

PFG

Witzel, Stamm, Janeway

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

(PEG)

E: EndoscopicG: GastrostomyJ: Jejunostomy

L: LaparoscopicNC: Needle CatheterS: Sonographic F: Fluoroscopic

These are the access points through the stomach and jejunum. Slide 12

Access and delivery

Nasogastric tube

PEG tube

Nasoentericor jejunal tube

These are the different tubes currently used. The earlier and still commonly used tube type is polyvinyl chloride (PVC) but it tends to be uncomfortable for the patient. The better quality and acceptability for the patient is obtained with polyurethane and silicon tubes. Silicon tubes tend to be smaller in internal diameter compared with polyurethane tubes so care to avoid clogging is very important for these tube types.


9

Slide 13

Gastrostomy

PEG placement 0

10

20

30

40

50

60

70

80

90

100

nu

mb

er 2000

2001

2002

2003

PEG placement,

St Luke’s Medical Center

Regarding gastrostomy: • Gastric access may be obtained for short-term feeding via the nasogastric route using

“blind” or manual placement at the bedside or with the use of radiologic guidance. • For long-term use, gastric access may be obtained via a gastrostomy placement using

endoscopic, radiologic, or surgical techniques. • The technique used for gastric access is based on the expertise of the physician placing the

tube as well as the patient’s condition. For example, if the patient has an esophageal tumor, the narrowed esophagus may prevent passage of the endoscope.

Rugeles S et al. Universitas Medica 1993;34(I):19-23.


10

Slide 14

Post-pyloric feeding

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

Short Term

Nasoenteric

– Nasoduodenal

– Nasojejunal

Long Term (operative)

Jejunostomy

– Percutaneous endoscopic

jejunostomy or through the

PEG tube

– Surgical jejunostomy

These are the different types of small bowel feeding where the end of the tube is in the small intestine. There is a short term use and long term use depending on the indication. If one foresees there will be slow recovery of oral intake in the post-operative period (beyond two weeks) it will be prudent to place a needle catheter jejunostomy and have it in place until the patient is able to achieve 70% oral intake of his requirements. • Gauderer MW, et al. J Pediatr Surg 1980;15:872-875


11

Slide 15

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)

What are the enteral nutrition formulas that are available? • Enteral formula categories include polymeric, both commercial and blenderized, oligomeric,

and disease-specific formulas. • Modular formulas include concentrated protein and carbohydrate preparations to enhance

protein and caloric content of enteral formulas. Slide 16

Enteral nutrition delivery

Gravity Feeding Enteral Pump Delivered

These are the modes of tube feeding delivery to the patient. Note that the nurses have specific protocols on how to feed the patient from positioning to rate and volume of delivery.


12

Slide 17

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)

Here are some practical points on 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)


13

Slide 18

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

More practical points in enteral nutrition: • If patient will undergo surgery and you doubt the 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


14

Slide 19

• 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

Monitoring Gastric Residuals

• High volume gastric residuals are associated with greater incidence of intolerance of enteral nutrition. Controlling gastric residuals before beginning nutrition and periodically after it has begun helps to reduce the possibility of bronchial aspiration.

• The presence of high volumes of gastric residuals indicates that close monitoring is required and that it may be necessary to hold tube feeding temporarily.

Mentec H, et al. Crit Care Med 2001;29:1955-1961. • Today, however, gastric residuals are managing by the following:

• Use of enteral pumps with adjustments of the volume and rate of delivery • Use of prokinetics • Standardized protocol for feeding

• There is no more excuse of holding feeding and forgetting to resume feeding for 24 hours


15

Slide 20

PARENTERAL NUTRITION

Parenteral nutrition still needs to be utilized more. This session will give more time in discussing this mode of nutrient delivery.


16

Slide 21

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.

These are the indications for parenteral nutrition use: • 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.


17

Slide 22

• 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.

Contraindications to PN

.* Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009; 28(4): 448.

These are the contra-indications to parenteral nutrition use: when the gut is viable and 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 (=able to have oral intake) 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.

Slide 23

Types of parenteral nutrition

Central• 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

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

These are the types of parenteral nutrition with their advantages and disadvantages


18

Slide 24


• Central parenteral nutrition

• Peripheral central parenteral nutrition

PICC =peripherally inserted central catheter

Just to show how the central parenteral nutrition catheter is placed nowadays – there is now a peripherally inserted catheter, but the more frequently used is still the subclavian approach. Slide 25

Catheters

Subclavian catheter (3 ports) PICC line catheters

These are the catheters used.


19

Slide 26


• Peripheral parenteral nutrition

These are the more common areas where peripheral parenteral nutrition is inserted.


20

Slide 27

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.

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


21

Slide 28

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”

1. Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382.2. Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2nd ed 2005; 97-107.

How is parenteral nutrition formulated?

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.


22

Slide 29

Formulation / Delivery

Break seal

Individualized delivery system

“All in one” placed in multi-chambered bags

• cheaper• stable• none to minimum

contamination

Compounding / clean rooms

Development

phases of the PN

container system

This is how parenteral nutrition preparation, formulation and delivery evolved. Now from a separate two or three bottle system connected by Y-connectors there is now one bag that contains the three major macronutrients.This system is called the “3 in 1” or “All in One” preparations. The issue of contamination and frequency of infections through the parenteral nutrition formulation and route has been drastically reduced. Storage time is increased and the cost involved in mixing solutions has remarkable gone down. Technology has definitely improved patient safety in parenteral nutrition delivery.


23

Slide 30

Safety issues

Three in one bags: longer storage

and less contamination

Protocols:1. Compounding2. Incorporation – additives3. Delivery (access, rates of

infusion, infusion pumps)

In-lineFilters:1. Fat emulsions2. Three in one

solutions3. Micro-

precipitates

These are the patient safety issues involved in parenteral nutrition preparation and delivery: • Compounding in a clean room is required • Three in one PN bags are preferred • On line filters for lipid emulsions are considered best practice


24

Slide 31

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.

These are the monitoring parameters for enteral and parenteral nutrition. The goal is to maintain normal status in both clinical and laboratory parameters. • 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.


25

Slide 32

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

These are the 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


26

Slide 33

OUTCOME IS DEPENDENT ON THE MONITORING PROCESS

Outcome is dependent on the monitoring process especially on the patient’s nutrient intake.


27

Slide 34

Feeding PathwaysCan the GIT be used?

Yes No

Parenteral nutritionOral

< 75% intake

Tube feed

Short term Long term

Peripheral PN Central PN

More than 3-4 weeks

No Yes

NGT

Nasoduodenal

or nasojejunal

Gastrostomy

Jejunostomy

“inadequate intake”

“Inability to use the GIT”

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.

The recommended cut-off value to say the patient has inadequate intake through either enteral or parenteral nutrition or combined is 75%. It means monitoring for calorie and protein intake on a regular basis is mandatory.

Slide 35

Calorie, protein,

fluid balance

form

This is the calorie, protein, and fluid balance form which is the standard data gathered by all members of the clinical nutrition service.


28

Slide 36

Nutrient monitor

form

This is the final nutrient monitor form which is placed in the patient’s medical record – this will show the attending physician on the status of his patient’s nutrition care.

Slide 37

Monitoring

This is the sample data entry.


29

Slide 38

DOCUMENTED OUTCOMES

We will show again these local data to reinforce the value of monitoring intake for surgical patients either pre-operative or post-operative.


30

Slide 39

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.

When adequate intake was achieved in both calorie and protein intake improvement in mortality and morbidity outcomes in the surgical patients were noted whether they are nutritionally high risk or low risk. In this study no significant difference is seen in the mortality rate. • 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. Accessed in: www.philspenonline.com.ph/Surg_Intake_ppr_slmc2.pdf


31

Slide 40

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)

Finally the nutrition team is the best group that can achieve consistency in results. That is the goal of the surgical nutrition module – to create a team for the surgical nutrition care in the department of surgery and eventually in the hospital

Slide 41

THANK YOU

LECTURE 6 BASICS OF ENTERAL AND PARENTERAL NUTRITION...

Documents

Transcript of LECTURE 6 BASICS OF ENTERAL AND PARENTERAL NUTRITION...