nutrisi enteral.lecture.ppt

8/23/2019 nutrisi enteral.lecture.ppt

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Hasanul Arifin

BAGIAN ANESTESIOLOGI DAN REANIMASIFAKULTAS KEDOKTERAN USU

MEDAN

Enteral Nutrition


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ENTERAL NUTRITION

SUPPORTI.Prerequisites

a functioning gastrointestinal tract

at least 100 cm of small bowel

condition of bowel adequate for absorption

patient incapable of adequate oral intake


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II. Advantagesless potential risk of infection, metabolic complication favours intestinal integrity and function maintains GI tract functions [ IgA, hormones, GALT ]

promotes gut motility reduces bacterial translocation from the gut less expensive product, delivery, monitoring


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III. Indications

evidence based indications existing malnutrition or risk of malnutrition

poor appetite or anorexia

prolonged fasting [>7 days]

supplementation of insufficient oral intake

for > 7 days

pragmatic indications severely stressed patients expected to be unable

to eat for 5-7 days or more severe trauma , burn

[following] small bowel resection

resumption of GI activity & preparation for oral

feeding


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IV. Contra Indication Obstruction of GI tract

Protracted vomiting or diarrhea

High output fistulas [> 500 ml] Diffuse peritonitis or ileus

Acute bowel ischemia / gut necrosis

Severe acute pancreatitis Severe short bowel syndrome [


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EVALUATE ENERGY + PROTEIN NEED

FUNCTIONAL GI-TRACT ?

NO CONTRAINDICATIONS TO EN ?

YES NOHighly catabolic state

(major trauma, burn surgery,septic shock)?

YES NO

Start PN Are conditions tostart EN present?

YES NO

Start continuous EN at500 ml/24h

Start PN andreassess daily

for conditions to

start EN

Gastric residual volume

>200ml

Reduce infusion rate by 50%4-6h, then progressiveincrease over 24-48 h

Monitor gastric residual volume 2/dayMonitor gastricresidual volume

Administer prokinetics(cisapride,metoclopramide, erythromycin)

Jolliet.P et al,Enteral nutrition in intensive care patients : a practical approach. Intensive Care Med 1998;24(8):848-859

Increase flowrate by 250-500 ml/day


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EN, administered by

Nasoenteric route

Percutaneous route


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Nasoenteric route Nasogastric, Nasoduodenal, Nasojejunal 2 -


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Nasoenteric Feeding Tube CompositionPVC Silicone PUR

Ease to insertion To stiff for comfort To soft Adequate

Ability to aspirate

gastric content

Excellent Poor to fair Good

Patient comfort Very poor Excellent Good

Durability/strength Strong but brittle Breaks easily Excellent/strong

Peggi Guenter: Delivery System Administration of Enteral Nutrition, inRombeau JL, Clinical Nutrition, Enteral and Tube Feeding,1997:244.


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Naso Gastric Tube

(NGT)


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Percutaneous route PEG, PEJ, combined nasogastric jejunal PEG, procedure of choice for ICU patients. [

4-6 weeks]

9-24Fr Relative CI, ascites, gastric cancer, gastric

ulcer, previous laparotomy, coagulation

disorder.

Post-pyloric feeding PEJ.


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PEG


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Classification of Tube Feeding Formulas

Polysaccharida, maltodextrin [60-70%NPC]

MCT, LCT [30-40% NPC]

Whole protein, partially hydrolyzed [35-40g/L formula] Isotonic [1.0-1.5 k.cal/ml]

standardised, iso osmotic (approximately 300 mOsm/L)

R/Panenteral, Nutren,

fiber enriched . R/Nutren Fibre

polymeric specialized for patients Diabetes, R/Nutren

Diabetes

Polymeric


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Elemental Chemically defined

Glucose, oligosaccharides

Crystalline amino-acids, peptide replace protein

Medium Chain Triglyceride

Specialized enteral formula [hepatic failure, renalfailure, stress-hypercatabolic ] BCAA, Glutamine

R/Peptivariant-2000

R/Peptamen


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Immune enhanced

Arginine, Glutamine, Ornithine -ketoglutarate

[OKG]

RNA

Omega-3-fatty acids

Nucleotide

R/NEOMUNE


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AlitraQ Impact Perative Stresson

units

Energy kcal/L 1000 1010 1300 1250

Protein g/L 52.5 56 66.6 75

Free-Gln g/L 15.5 0 12.2 13

Arginine g/L 4.5 12.8 8.1 9

Nucleotide g/L 0 1.3 0 0

Lipids Safflower oil Palm oil Canola oil Vegetable oil

MCT Safflower oil Corn oil Fish oil

Menhaden oil MCT Vegetable, fish

Omega-3-FA g/L 0.02 3.3 1.24 1.1

Antioxidants yes yes yes yes

Manufactured products Immune Enhanced


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Intermittent (bolus)

Administering tube feeding

naso gastric tube, gastrostomy

head up position 300

start gastric feeding of 150-200ml over 20-40 minutes,

increase by 50-100ml each feeding as tolerated to goal

followed by 30 ml warm water flush

check residuals before next feeding (up to half)

for sign of intolerance (diarrhea, vomiting), reduce to lasttolerated step, evaluate clinically.


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Continuous (drip infusion) Intragastric, duodenal, jejunal Start at 30-50 ml/hr isotonic formula

Increase by 30-50/hr every 6-8 hours to goal

Maximum 100-150ml/hr

Most tube fedings are tolerated at full strength Reduce risk ( retention, aspiration)

followed by 30 ml warm water flush

for sign of intolerance (diarrhea, vomiting),reduce to last tolerated step, evaluate clinically.


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Continuousdripinfusion


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EN + PEN


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Monitoring, Metabolic, gastrointestinal, mechanical assessment

Routine dayli evaluation of intake,output, weight

Acutely ill patients require daily to weekly serum

electrolyte, glucose, BUN, Cr, Ca++, Mg++, Ph. Stable patients require weekly-monthly laboratory

studies

Elevate head of bed 300 during feeding

Check stomach for high residuals to minimizeaspiration risk


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Metabolic : overhydration, dehydration,undernutrition, hyperglycemia,electrolyte imbalance

Gastrointestinal : nausea, vomiting, constipationabd. discomfort, diarrhea

Mechanical : misplaced, clogged feeding tubeairway, GI tract injury with NG/NJ

tube placement. Infectious : peritonitis, exit site infection, sinusitis,

aspiration pneumonia

Complications,


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nutrisi enteral.lecture.ppt