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 patients dietary requirements ID: 917215
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Slide1
Nutritional support
Slide2Nutritional 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
Slide3Critically 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.
Slide4Early 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.
Slide5Enteral
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.
Slide63. 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.
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.
Slide8Gastric 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).
Slide9Micro 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.
Slide10Patients 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
.
Slide11On 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.
Slide12So 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.
Slide13Types of
Enteral
feeding catheters
Nasogastric tube
Nasojejunal
tube
Surgical gastrostomy
tube
PEG tube (percutaneous endoscopic
gastrojejunostomy
and
jejunostomy
tubes.
Surgical
jejunostomy
tube
Slide14Slide15Tube
f
eeding formulations
Standard polymeric
Elemental or small peptide
Disease specific
Slide16Composition 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.
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.
Slide18Standard 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
Slide19Slide20Disease 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.
Slide21Renal 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
Slide22Monitoring 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.
Slide23Contraindications for EN
Severe acute pancreatitis
High output proximal fistula
Inability to gain access
Intractable vomiting or diarrhea
Aggressive therapy not
warranted
Slide24Inadequate resuscitation or hypotension; hemodynamic instability
Ileus disease
Intestinal obstruction
Severe G.I. Bleed
Contraindications for EN
Slide25Slide26Nasogastric 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
Slide27Nasogastric 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
Slide28Nasogastric
Tubes
Slide29Nasoduodenal
/
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
Slide30Nasoduodenal
/
Jejunal
Disadvantages:
Transpyloric
tube placement may be difficult
Limited to continuous infusion
May promote nasal necrosis and esophagitis
Impacts patient quality of life
Slide31Orogastric
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
Slide32Enterostomy
Placement
Gastrostomy
Jejunostomy
Slide33Gastrostomy
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
Slide34Gastrostomy
Disadvantages:
May require surgery
Stoma care required
Potential problems for leakage or tube dislodgment
Slide35Gastrostomy
Slide36Jejunostomy
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
Slide37Jejunostomy
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
Slide38Jejunostomy
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)
Slide39Determining Method of
Administration
Feeding site
Clinical status of patient
Type of formula used
Availability of pump
Mobility of patient
Slide40Enteral Feeding Complications
Mechanical
Gastrointestinal
Metabolic
Infectious
Slide41Aspiration
Tube obstruction
Tube displacement
Mechanical complication
Slide42Aspiration
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.
Slide43Aspiration pneumonia develops in 43% of patients on nasogastric tube feeding and in 56% of patients with a gastrostomy.
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
Slide45Treatment 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
Slide46Gastrointestinal Complications
Diarrhea
Constipation
Gastric distention/bloating
Gastric residuals/delayed gastric emptying
Nausea/vomiting
Slide47Diarrhea
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
Slide48Causes
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).
Slide49Drug-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
Slide50Nausea/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.
Slide51Nausea/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
Slide52Metabolic
Fluid and Electrolyte abnormalities
Glucose intolerance
Ca
++
, Mg
++
, PO
4
abnormalities
Other
Slide53Fluid 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
Slide54Hyperglycemia:
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
.
Slide55H
ypoglycemia,
caused by:
Sudden cessation of feeding can be prevented by frequent monitoring of blood sugar if feeding is interrupted.
Slide56Dehydration
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
Slide57Overhydration
, 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.
Slide58Refeeding
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
Slide59Refeeding
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
Slide60Infectious Complications
Formula contamination
Unsanitary equipment
Failure to follow appropriate protocols re handling of enteral
feedings/changing of
bags and tubing
Slide61Monitoring of Patients on EN
Electrolytes
BUN/Cr
Albumin/
prealbumin
Ca
++
, PO
4
, Mg
++
Weight
Input/output
Vital signs
Stool frequency/consistency
Abdominal examination