Nutrition Support

Delivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status

Two types:enteral – delivery of nutrients into GI tract through a tube parenteral – delivery of nutrients into blood steam intravenously

Why enteral support is thought to be better (than parenteral)

By putting the nutrients into the gut, the gut mucosa keeps toxic substances from getting into the bloodstream & causing sepsis

1.GALT (gut associated lymphoid tissue) is part of immune system – provides 70% of body antibodies & contains lymphocytes

2. Maintain healthy bacteria in gut 3. Can give probiotics (lactobacillus)4. Can give prebiotics (fiber &

fructooliogosaccharides FOSs)

Enteral Feeding:indications for use

impaired food ingestion: dysphagia, unconscious, fractured mandible, respiratory failure, inability to suck (premature infants)

impaired digestion of whole (intact) foods: chronic pancreatitis, Crohn’s disease, short bowel syndrome

cannot meet nutritional requirements: major burn, trauma, anorexia nervosa, severe wasting

When the gut works, use it!safer - less risk of infection less expensive more easily done at home than parenteralUnderstand figure 23-1

Routes (access sites) for tube feeding depend:

How long will feeding be needed?Risk for aspiration of feeding into lungsSurgical risk or no riskSites:

1. Nasal gastric (NG) Nasalduodenal or Nasojejunal

2.Postpyloric- Gastrostomy-most common is PEG Jejunostomy- PEJ

Tubes in nasal cavity

NG - nasogastric: short-term 3-4 wks, pt has low-risk of aspiration (intact gag), normal digestion

NJ – nasojejunal (postpyloric): short-term, pt with high risk of aspiration, gastric or duodenal surgery or disease

X Ray to verify placement of a tube

Gastrostomy (G Tube): for long-term feedings

Need functioning stomach & intestinesmore comfortable, for long term use >

4 weeksPEG (Percutaneous endoscopic

Gastrostomy) a procedure using endoscope to put special tube down into stomach & out abdominal wall

other “G” tubes surgically placedmay use jejunum – jejunostomy, PEJ

Reasons not to use Enteral Support

ileus - no bowel soundssmall bowel obstruction - SBOsevere diarrhea or vomitingrefusal of nutrition support by

patient or through Advance Directive high-output fistula (>500 cc/day)acute pancreatitiscan eat adequate amount by mouth

Choices for Enteral Formula3 major types

Is GI tract functioning normally? YES = intact or polymeric formula NO = hydrolyzed formula

(monomeric)with polypeptides or amino acids & some MCT oil

when disease specific formulas warrented: renal, diabetes, hepatic, pulmonary, severe stress & trauma

Immune Boosting Properties in Enteral Feedings

Impact, Perative, Crucial (p 1233)Glutamine: primary energy source for

rapidly ÷ cells; increases T cell productionArginine: increases T cellsOmega-3-fatty acids: causes less

inflammation in cells, increases N balanceNucleotides: used to form DNA

Enteral Formula Selection: other factors to consider

Age - special formulas for pediatricsCaloric density 1 kcal/cc to 2 kcal/ccProtein density of formula (g/liter)Na, K, Mg, P content?Would fiber be beneficial?CHO sources in formulas: hydrolyzed

corn starch, maltodextrin, soy fiber, corn syrup solids - all lactose-free

Enteral Formula Selection

Osmolality (size and number of nutrient particles in a solution). If high (600 - 900 mOsmol/kg) fluid drawn into gut diarrhea

Example: Osmolite = 1.06 kcal/cc, 14% pro, 57% CHO, 29% fat, Cal:N 178, Osmol 300, 1887 cc to get RDA, 80% free water, casein & soy pro, maltodextrin, safflower, canola, MCT

Tube Feedings

at home, person with healthy immune system, could use home made blenderized tube feeding

water is used to “flush” or clean the tube - this water is part of individual’s fluid requirement & given during the day

How are tube feedings given?

1. Continuous drip using a pump

2. Intermittent drip using a pumpif person eats some food during the day tube feeding may be given at night

3. Bolus using gravity instead of pump; given as a bolus 4-6 bolus times/day

How is a patient on tube feeding monitored?

gastric residuals (checked by RN)stool frequency and consistency urine output adequate (I and 0) change in wt ↓Na, K, BUN, creatinine, glucosealbumin or prealbumin, Ca, P, Mg seen/charted by RD every 3-7 days

Complicationsof Tube Feeding

diarrhea high gastric residualsconstipationaspiration pneumonia – tube

feeding into lungspt pulls out tube

Complicationsin patient on tube feeding

hyperkalcemiaazotemia (BUN, Cr due to ECF) prerenal azotemia: BUN > Cr

10:1hyponatremiahyperglycemiahypoglycemia

How much tube feeding does one give?

1. Determine the number of kcal pt needs during nutrition assessment

2. Decide site for access & type of tube feeding needed

3. Kcal needed day kcal ÷ ml of feeding = cc needed/ 24 hrs

Example: 1. use NG tube, Nutren 1.0 with fiber2. pt needs 1629 kcal/day÷ 1.0 kcal/cc3. 1629 ÷ 24 (hr) = 68 cc/hr continuous drip

Parenteral Nutrition - indications for use

GI tract is not functioning well enough to meet nutritional needs of patient so nutrients put in bloodstream intravenously

examples:small bowel resection small bowel obstructionlarge output fistula below enteral

feeding site

Parenteral Nutrition – access sites (where it can go into the bloodstream)

Central access: requires surgical placement of catheter in large, high blood flow vein (total parenteral solution TPN)

PICC line: “tunneled” catheter inserted in vein in arm; solution taken to high blood flow vein (TPN)

Peripheral access: catheter tip placed in vein in arm. Requires a more dilute peripheral parenteral solution. (PPN)

Solutions: CHO = D15

Supplied as dextrose: 10% to 35% 10%= 100 gm/L, 25% = 250 gm/Ldextrose = 3.4 Kcal/gm 1 liter of 10% soln=(100gm x

3.4Kcal/gm = 340 Kcal)PPN- Peripheral Parenteral Nutrition

is put into small (peripheral) vein so cannot use more than D1o

Solutions: Protein = D15 with 2.5% aa @ 60cc/hr

supplied as aa both essential & nonessential: choices:

2.5, 4.25, 5% solutions (2.5% = 25 gm/L 4.25% soln = 42.5 gm/L)

protein =4 Kcal/gm; often not be included in total Kcal

60 cc x 24 = 1.44 L x 25 g/L = 36 gms in 24 hrs & 144 kcal of prot

1.44 L x 150 gm/L = 216 g dextrose x 3.4 kcal/gm = 734 kcal in 24 hrs

Parenteral Nutrition Solutions: Lipids

Supplied as aqueous suspension of soybean or safflower oil with egg yolk phospholipids as the emulsifier. Glycerol is added to suspension.

2 levels of emulsions:10% solution: 1.1 kcal/mL

20% solution: 2.0 kcal/mL

D15 with 2.5% aa @ 60cc/hr and 10% IL at 11 cc/hr

11 cc/hr x 24 hr = 264 cc x 1.0 kcal/cc = 264 kcal/day

Total kcal: 1142 Kcal from fat: 264 (23%)Kcal from CHO: 734 (64%)Kcal from prot: 144 (13%)

Parenteral Nutrition Solutions

Guidelines for amounts of each to provide:Protein: 15 - 20% of kcalLipids: ~30% of kcal CHO: 50-65% of kcalElectrolytes, vitamins, trace elements:

lower than DRI Fluid: 1.5 - 2.5 liters totalKcal: N ration: 125 kcal:1 gm N

Parenteral Nutrition Solutions

Prepared aseptically & delivered 2 ways:“3 in 1” solution: pro,fat,CHO in one bag

and 1 pump is used to infuse solution2 bag method: pro & CHO in 1 bag & lipid

soln in glass bottle; each is hooked up to pump; solutions enter vein together

Given continuously or cyclic (8-12 hrs/day)Insulin may be added to solution

Parenteral Nutrition Solutions: Selected Complications

Mechanical: thrombophlebitisInfection and sepsis of catheter siteGastrointestinal: villous atrophyMetabolic: hyperlipidemia, trace

mineral deficiencies, electrolyte imbalance, refeeding syndrome

Refeeding syndrome

Transitional Feeding

A process of moving from one type of feeding to another with multiple feeding methods used simultaneously

Examples:parenteral feeding to enteral feedingparenteral feeding to oral feeding

enteral feeding to oral feeding

Transitional Feedingparenteral to enteral

1. Introduce enteral feeding – 30 cc/hr while giving parenteral

2. If tolerated, gradually ↓ parenteral while increasing enteral

3. Once pt can tolerate 75% of needs enterally, d/c parenteral

Process is called a stepwise decrease

Transitional Feedingparenteral to oral and enteral to oral

Use step-wise decrease method; wait until pt accepting 75% oral and then decrease parenteral or enteral method

But may need to:Offer oral during the day & cycle other from

6pm -6am in order to ↑ provide motivation & reestablish hunger patterns

Some children & adults may continue on oral during the day and enteral at night

Nutrition Support

most effective when provided as a team: RD, RN, Pharm D in conjunction with MD

Various substances being investigated for therapeutic effects

$$ so look for articles on cost-benefitKnow patient wishes for use – living

will and if there is an advance directive