Nutritional support Nutritional support - PowerPoint Presentation

Slide1

Nutritional support

Slide2

Nutritional support

:

includes:

the use of artificial feeding methods such as tube feeding (

E

nteral feeding

), total parenteral nutrition (

TPN)

and administration of intravenous fluids.

Nutritional support means the provision of patient's dietary requirements

Slide3

Critically ill patients are often unable to eat because of certain conditions:

1-Endotracheal intubation.

2-The need for mechanical ventilation.

3-Altered level of consciousness as a result of severe trauma, major surgery or acute medical condition.

Lack of nutrients may

:

1-Alter

the structure and function of the gut.

2-Increase the risk of entry and spread of intestinal bacteria.

Slide4

Early nutritional support

for critically ill patients has been advocated to:

1-Promote the immune system recovery

2-prevent as much as tissue breakdown

3-avoid nutritional deficit as possible

4-Improves patient outcomes.

5-Enhances recovery from illness.

Slide5

Enteral

N

utrition

Enteral Nutrition or tube feeding is a way of providing nutrition support via the GIT for patients unable to otherwise meet nutrition requirements by the oral route.

Enteral feeding has several advantages over total parenteral nutrition

:

EN

has been shown to be easier, safer and cheaper than PN.

EF

maintains the structure and functional integrity of the gastrointestinal tract by intraluminal delivery of nutrients and preventing atrophic changes.

Slide6

3. EF preserves the normal sequence of intestinal and hepatic metabolism, fat metabolism, lipoprotein synthesis and prevents cholestasis by stimulating bile flow.

4. Maintains

normal insulin / glucagon

ratio.

5. Reduction

in septic complications with EF compared with PN.

6. EF

improves systemic immunity and lower infection risk.

7. Prevents

translocation of bacteria into the systemic circulation and reduce the incidence of sepsis.

Slide7

On the other

hand,

intragastric

EN often is complicated by intolerance, as indicated by elevated volumes of aspirated gastric residual.

High gastric residual

is a return of at least half of the hourly feeding rate.

It is commonly accepted that high gastric residual volume

enhances

regurgitation and increases the risk for aspiration pneumonia.

Slide8

Gastric residual

is the amount of previous feeding remaining in the stomach .

This fluids

commonly accumulate in the gastrointestinal tract of a tube fed patient include the

1-Feeding

formula

2-Swallowed saliva (> 0.8 L/ day),

3-Gastric secretion (1.5 L/ day),

4-Small bowel secretion regurgitated into the stomach (2.7 – 3 L/ day).

Slide9

Micro aspiration

– Aspiration of small volume that is usually

asymptomatic and

clinically undetected

.

Macro

aspiration – Aspiration of large volume that is

usually detected

by clinical observation.

Silent

aspiration – Aspiration occurring in the absence of acute symptoms.

Symptomatic

aspiration – Aspiration accompanied by acute clinical

symptoms of

coughing, choking, dyspnea, or respiratory distress.

Slide10

Patients receiving

isotonic

formulas who are given

too much fluid

may show signs of fluid excess such as weight gain, edema and may develop

dilutional

hyponatremia

.

Slide11

On the other hand, patients receiving

hypertonic

, high-protein feedings who do not ingest enough fluid are at risk for life-threatening condition called

tube-feeding syndrome

, characterized by fluid-volume deficit, hypernatremia,

hyperchloremia

and azotemia.

Slide12

So it is very important to monitor and assess fluid intake and output such as

1- body weight,

2- edema and respiratory rate,

3- blood urea nitrogen and other electrolytes.

Slide13

Types of

Enteral

feeding catheters

Nasogastric tube

Nasojejunal

tube

Surgical gastrostomy

tube

PEG tube (percutaneous endoscopic

gastrojejunostomy

and

jejunostomy

tubes.

Surgical

jejunostomy

tube

Slide14

Slide15

Tube

f

eeding formulations

Standard polymeric

Elemental or small peptide

Disease specific

Slide16

Composition of commercially prepared formulas:

Protein content from 6 to 26%

Can be made with casein, soy, hydrolyzed protein with added amino acids, or free amino acids alone.

Carbohydrate content from 28 to 90 %

Can be made with starch, glucose polymers, and/or disaccharides such as sucrose.

Fat content from < 1% to 55%

Can be made with LCTG, MCTG, and fish or other specially oil.

Slide17

Formula selection

Standard/polymeric tube feedings require some degree of digestive and

a

bsorptive capacity.

Elemental/Peptide tube feedings are recommended for patients with

malabsorption

, pancreatitis, short bowel syndrome and/or dysfunction.

Slide18

Standard formula composition

Protein content

10-15 %

Carbohydrate

content 50-60 %

Fat content 30-35 %

Some patients may require different preparations because of specific disease states such as diabetes, renal or hepatic disease

Slide19

Slide20

Disease Specific Formulations

Glucose intolerance formula:

Prepared with less % total carbohydrate content

Hydrolyzed cornstarch, usually higher fat content

Immune function formula:

Contain added amount of glutamine, arginine, beta-

carotine

, nucleic acids and fish oil.

Hepatic dysfunction formula:

Increase content of high BCAA and lower conc. of aromatic amino acids, reduce sodium content, high calorie to reduce volume needed to meet nutritional needs.

Slide21

Renal dysfunction formula:

High calorie, high protein, modified level of electrolytes and specific alterations in vitamin and mineral content.

Trauma formulation:

High protein, high calorie, some with increased BCAA content, some with added glutamine, arginine, special fat blends, increased levels of copper and zinc.

Wound healing formulation:

High protein and

h

igh content of vitamin A, vitamin C and zinc.

Disease Specific Formulations

Slide22

Monitoring tube feeding tolerance

Gastric residuals: volume aspirated from a feeding tube placed in the stomach should not exceed 250 ml volume.

Abdominal distension.

Diarrhea.

Constipation.

Slide23

Contraindications for EN

Severe acute pancreatitis

High output proximal fistula

Inability to gain access

Intractable vomiting or diarrhea

Aggressive therapy not

warranted

Slide24

Inadequate resuscitation or hypotension; hemodynamic instability

Ileus disease

Intestinal obstruction

Severe G.I. Bleed

Contraindications for EN

Slide25

Slide26

Nasogastric Tubes

A

tube inserted through the nasal passage into the stomach

Indications:

Short term feedings required

Intact gag reflex

Gastric function not compromised

Low risk for aspiration

Slide27

Nasogastric Tubes

Advantages:

Ease of tube placement

Surgery not required

Easy to check gastric residuals

Accommodates various administration

techniques

Disadvantages:

Increases risk of aspiration (

may be

)

Not suitable for patients with compromised gastric function

May promote nasal necrosis and esophagitis

Impacts patient quality of life

Slide28

Nasogastric

Tubes

Slide29

Nasoduodenal

/

Jejunal

A

tube inserted through the nasal passage through the stomach into the duodenum or

jejunum

Indications:

High risk of aspiration

Gastric function

compromised

Advantages:

Allows for initiation of early enteral feeding

May

decrease risk of aspiration

Surgery not required

Slide30

Nasoduodenal

/

Jejunal

Disadvantages:

Transpyloric

tube placement may be difficult

Limited to continuous infusion

May promote nasal necrosis and esophagitis

Impacts patient quality of life

Slide31

Orogastric

Tube is placed through mouth and into stomach

Often used in premature and small infants as they are

nasal breathers

Not tolerated by alert patients; tubes may be damaged by teeth

Slide32

Enterostomy

Placement

Gastrostomy

Jejunostomy

Slide33

Gastrostomy

A feeding tube that passes into the stomach through the abdominal wall. May be placed surgically or

endoscopically

.

Indications:

Long-term support planned

Gastric function not compromised

Intact gag reflex present

Slide34

Gastrostomy

Disadvantages:

May require surgery

Stoma care required

Potential problems for leakage or tube dislodgment

Slide35

Gastrostomy

Slide36

Jejunostomy

A

feeding tube that passes into the jejunum through the abdominal

wall, may

be placed

endoscopically

or surgically

Indications

:

Long-term feeding option for patients at high risk for aspiration or with compromised gastric function

Slide37

Jejunostomy

Advantages:

Post-op feedings may be initiated immediately

Decreased risk of aspiration

Suitable option for patients with compromised gastric function

Stable patients can tolerate intermittent feedings

Slide38

Jejunostomy

Disadvantages:

Requires stoma care

Potential problems related to leakage or tube dislodgement/clogging may arise

May restrict ambulation

Bolus feedings inappropriate (stable patients may tolerate intermittent feedings)

Slide39

Determining Method of

Administration

Feeding site

Clinical status of patient

Type of formula used

Availability of pump

Mobility of patient

Slide40

Enteral Feeding Complications

Mechanical

Gastrointestinal

Metabolic

Infectious

Slide41

Aspiration

Tube obstruction

Tube displacement

Mechanical complication

Slide42

Aspiration

is the most dangerous mechanical complication associated with EF.

Pulmonary aspiration of EF with subsequent pneumonia is a frequent and serious complication of enteral nutrition in critically ill adults despite the presence of cuffed and properly inflated endotracheal tubes.

Slide43

Aspiration pneumonia develops in 43% of patients on nasogastric tube feeding and in 56% of patients with a gastrostomy.

Slide44

Causes of Feeding

Tube Obstruction

Concentrated, viscous, and fiber-containing feeding products

Tube feeding contamination

Checking of gastric residuals

Small diameter tubes

Powdered or crushed medication flushed through tubes

Acidic or alkaline medications passed through tubes

Tubes not routinely flushed after feedings are stopped

Slide45

Treatment of Feeding Tube Obstruction

Declog

with

irrigants

(warm water) or sodium bicarbonate/

pancrealipase

mixture or by mechanical means

Cola beverages, cranberry juice, and tea not recommended

Slide46

Gastrointestinal Complications

Diarrhea

Constipation

Gastric distention/bloating

Gastric residuals/delayed gastric emptying

Nausea/vomiting

Slide47

Diarrhea

Definition: >500 ml every 8 hours or more than 3 stools a day for at least two consecutive days. Relates more to stool consistency than frequency

Diarrhea was a common consequence of enteral feedings when

hyperosmolar feedings

were routinely delivered via syringe

Occurs in 2 to 63% of

enterally

-fed

pts

depending on how defined

Slide48

Causes

of Diarrhea

Intestinal atrophy due to

malnutrition.

Use

an infusion pump to regulate

flow.

Bacterial overgrowth of intestinal tract or contamination of the enteral

feeding.

Steatorrhea

: characterized by frothy, odiferous stools that float on water; caused by fat

intolerance.

Lactose intolerance (lactose free

& eliminate

milk and dairy

products).

Slide49

Drug-induced

diarrhea

Meds may cause up to 61% of diarrhea in

tube fed patients

due to

hypertonicity

or direct laxative action (magnesium, sorbitol,

potassium), and it is common

with antibiotics.

GI

disease: such as IBS, short gut, celiac disease, AIDS

May require PN or specially formulated EN

Causes

of Diarrhea

Slide50

Nausea/Vomiting

20% of patients on EN report nausea/vomiting

Often related to delayed gastric emptying caused by hypotension, sepsis, stress, anesthesia, medications (analgesics and

anticholinergics

),

surgery.

Slide51

Nausea/Vomiting Treatment

Consider reducing/discontinuing narcotic medications

Switch to a

lowf

at

formula

Administer feeding solution at room temperature

Reduce rate of infusion by 20-25 ml/

hr

Administer

prokinetic

agent (metoclopramide, erythromycin,

domperidone

,

bethanechol

)

Check gastric residuals

Consider

antiemetics

Slide52

Metabolic

Fluid and Electrolyte abnormalities

Glucose intolerance

Ca

++

, Mg

++

, PO

4

abnormalities

Other

Slide53

Fluid and Electrolyte Disturbances

May result from long term nutrition deficits, acute stress, medications, medical conditions, improper nutrient prescription

Electrolytes lost via stool, urine,

ostomy

or fistula drainage

Dehydration most common complication (tube feeding syndrome) especially with high protein feeding and insufficient fluid

Slide54

Hyperglycemia:

c

omplication

that can be caused by high carbohydrate formula and Hyperosmolar feeding of fluid overload.

Hyperglycemia can be prevented by:

1- Monitoring

for fluid balance, urine and blood for glucose.

2- Administering

insulin on a sliding scale if necessary

3- Changing

the formula to lower calorie content and observing for

hypercapnea

.

Slide55

H

ypoglycemia,

caused by:

Sudden cessation of feeding can be prevented by frequent monitoring of blood sugar if feeding is interrupted.

Slide56

Dehydration

caused by:

1-High osmolality formula.

2-Diarrhea and excessive protein intake with inadequate fluid intake.

3-Large amount of fluid that can be lost during prolonged uncorrected vomiting and diarrhea without adequate replacement of fluid and electrolytes.

4- gastric

and intestinal suctioning occur without the proper monitoring

Slide57

Overhydration

, can be caused by:

1-Fluid overload,

2-When the metabolic demands are high and the organ function is impaired namely cardiac, renal or hepatic.

Management of

Overhydration

:

1-Restricting free water intake

2-Changing to concentrated formula

3-Administering diuretics

4-Decrease the delivery rate.

Slide58

Refeeding

Syndrome

At risk: when

refeeding

those with marginal body nutrient stores, stressed, depleted patients, those who have been unfed for 7-10 days, persons with anorexia nervosa, chronic alcoholism, weight loss

Symptoms: Hypokalemia, hypophosphatemia and

hypomagnesemia

; cardiac arrhythmias, heart failure; acute respiratory failure

Slide59

Refeeding

Syndrome

Correct electrolyte abnormalities (via oral, enteral, parenteral route) before initiating nutrition support

Administer volume and energy slowly

Monitor pulse rate, intake and output, and electrolyte levels

Provide appropriate vitamin supplementation

Avoid overfeeding

Slide60

Infectious Complications

Formula contamination

Unsanitary equipment

Failure to follow appropriate protocols re handling of enteral

feedings/changing of

bags and tubing

Slide61

Monitoring of Patients on EN

Electrolytes

BUN/Cr

Albumin/

prealbumin

Ca

++

, PO

4

, Mg

++

Weight

Input/output

Vital signs

Stool frequency/consistency

Abdominal examination