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NUTRITION SUPPORTNoraishah Mohamed Nor
Dept Nutrition Sc
IIUM
INTRODUCTION
CONDITIONS THAT REQUIRE SPECIALIZEDNUTRITION SUPPORT
Enteral—Impaired ingestion—Inability to consume adequate nutrition orally—Impaired digestion, absorption, metabolism—Severe wasting or depressed growth
ParenteralGastrointestinal incompetency (diminished
intestinal fx)Hypermetabolic state with poor enteral
tolerance or accessibilitySupplement to EN
CONDITIONS IN ENDiminished food intake
Preoperative malnutritionComaPostoperative ileus
Hypercatabolic statesPolytraumaBurnSepsisSevere disease condition
Diminished digestion and absorptionPyloric stenosisPancreatic diseaseBiliary diseaseMalabsorbtion syndromeShort bowel syndromeRadiation enteritisUlcerative colitisDuodenal fistula
Chronic diseaseChronic cardiac, hepatic, renal diseaseMalignant disease
Changes in metabolic rate and nitrogen excretion with various types of physiologic stress
INDICATIONS FOR ENTERAL NUTRITION
Inadequate amount nutrients and/or calories ingested will lead to malnutrition- associated with an increased incident of: Poor wound healingImpaired immune response and
response to traumaIncreased risk of sepsisAltered gut structure/function
causing malabsorption and spread of bacteria
Ultimately malnutrition will lead to: Prolong recovery period Increased need for nursing care Increased risk of serious complications Prolong hospital stay Increased medical cost
CONTRAINDICATIONS FOR EN
Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Inadequate resuscitation or hypotension;
hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if
malnourished or 7-9 days if normally nourished
ADVANTAGES - ENTERAL VS PN
Preserves gut integrity Possibly decreases bacterial translocation Preserves immunological function of gut Reduces costs Fewer infectious complications in critically
ill patients Safer and more cost effective in many
settings
ADVANTAGES - ENTERAL NUTRITION
Intake easily/accurately monitored Provides nutrition when oral is not possible
or adequate Supplies readily available Reduces risks associated with
disease state
DISADVANTAGES—ENTERAL NUTRITION
GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax
Costs more than oral diets (not necessarily) Less “palatable/normal”: patient/family
resistance
Labor-intensive assessment, administration, tube patency and site care, monitoring
DISADVANTAGES - PN
Gut mucosal athropy Overfeeding Hyperglycemia Increased risk of infectious complications Increased mortality in critically ill pt
AIMS OF NUTRITIONAL SUPPORT
Preserve lean body mass (protein) Increase protein synthesis Improve immune and muscle function More rapid recovery Shorten hospital stay Reduction of morbidity
ROLES OF NUTRITION SUPPORT DIETITIAN
Working with other health care professionals inc. pharmacist, nurse, clinician-to support, restore, maintain optimal nutritional health for individuals with potential or known alterations in nutritional status
Assures optimal nutrition support though implementation of nutrition care process related to delivery of EN and PN support (Fuhrman et al 2001)
Nutrition care process
Individual nutritional status assessment
Indentify nutritional diagnosis
Implement appropriate interventions
Monitor & reassess an individual’s response to the nutrition
care delivered
Evaluate outcomes-incl. the need for transitional feeding care plan or termination of nutr. Support intervention
(Lacey & Pritchett, 2003)
ALGORITHM TO CHOOSE NUTRITIONAL SUPPORT
Nutritional assessment of the patient
Normally nourishedNormally nourished but will develop malnutrition because of disease process if support withheld
malnourished
Normal feeding Nutritional support indicated
DIFFERENT WAYS TO PROVIDE NUTRITION SUPPORT
Oral Enteral Parenteral Combined
WHEN THE GUT WORKS – USE IT!
SIGNS OF FUNCTIONING GIT
The present of bowl sound Soft, non-tender abdomen Passage of fistulas/stool Intact appetite
ENTERAL NUTRITION BY MOUTH
Common sense Adequate Palatable Varied Nutritional complete Provided at regular intervals, more frequentyly
than regular meal times if necessary Progressively increasing in heaviness and
complexity
Cleanliness In preparation and serving of food and utensils to
prevent GIT infection
Compassion Ensuring the patient ingests the preferred food Putting food in patient’s reach Conducive eating environment Involving dietitians in food selection and preparation
ENTERAL NUTRITION BY TUBE Nutrition provided through the gastrointestinal tract via a tube,
catheter, or stoma that delivers nutrients distal to the oral cavity
Benefits of EN: Help maintain gut mucosal physiology
May modulate immune response-prevent translocation of bacteria and toxins (maintain gut mucosal integrity)- IgA in EN (IgA prevent absorption of enteric antigents)-less risk for infection
Promote peristalsis
Safer: fewer complication
Lower cost-formula, delivery system and less patient care
Simpler system-care and self-administrator
CLINICAL SETTING IN WHICH ENTERAL NUTRITION SHOULD BE PART OF ROUTINE CARE
PEM with inadequate oral intake of nutrients for the previous 5 days
Oral intake <50 % of required needs for the previous 7-10 days
Severe dsyphagia due to strokes, brain tumors, head injuries, multiple sclerosis
Major (>30 % of BSA), full thickness burns
Short gut due to small bowel resection-enteral nutrition + parenteral nutrition to stimulate regeneration of the remaining intestine
Clinical conditions in which enteral nutrition usually may be helpful:
Major trauma with functional GIT + inadequate oral intake for 7-10 days
Radiation therapy for cancers of the lungs, head, neck and cervix, and lymphomas
Acute/chronic liver failure + severe anorexia + functioning GIT
Severe renal dysfunction (<5% of normal glomerular filtration) + anorexia + functioning GIT
Contraindications for enteral feeding: Mechanical obstruction of GIT Prolong ileus Severe GI haemorrhage Severe diarrhoea Intractable vomiting High-output GIT fistula (>500 ml/day) Severe enterocolitis
TUBE FEEDING ROUTES
TRANSNASAL PASSAGE
Transnasal passage of feeding into the stomach/intestine employed when possibleA surgical procedure can be avoidedGenerally well tolerated when small-bore
feeding tube are usedDisadvantages:
tube can be readily removed by disorientated/uncooperative px.
When larger, stiffer tube used-irritation to nasal passages, pharynx, esophagus & compromise gastroesophageal competency
Nasogastric insertion & placement of the tube is easier.
Nasogastric, esophagostomy, gastrostomy feeding allow the digestive process to begin in
the stomach-decreasing risk of dumping syndrome.
Disadvantage:higher risk of aspiration-only gastroesophageal sphincter is operating to prevent reflux
Nasoduodenal, nasojejunal, jejunostomy:Advantage:
Posed less risk of regurgitation-advantage of gastroesophageal sphinctar & pyloric sphincters
Disadvantages: Higher risk of intolerance (nausea,
vomiting, diarhea, cramps)-when feeding are not properly selected.
The bactericidal effect of HCL in the stomach is bypassed-need attention for sanitation to formula and equipment
OSTOMIES
Require surgical insertion. Indicated when insertion through
transnasal is impossible or when long-term feeding is anticipated
Advantages: irritation caused by the feeding tube is
eliminatedOstomies are unobtrusive between feeding
time
Jejunostomies: Advantage:
permits early post operative feeding (unlike stomach & colon)-the small bowel is not affected by postoperative ileus.
Relatively safe, comfortable, potential for long-term use
Disadvantage: Possibility of infection is high like
other ostomy procedure
EN ADMINISTRATION
Administration of EN should be guided by: Px’s age Underlying disease Enteral access device Condition of GI
When the patient should be started with EN? Eary initiation of EN is beneficial if px is
hemodynamically stable In ICU, when EN was initiated within 24-48 hrs
of admission: Lower rates of infection Shorter hospital stay
(Bar et a. 2004)
METHODS OF DELIVERY
Based on: Nutrient needs Feeding site Formula selection Current medical status
3 methods of delivery:1. Bolus feeding2. Intermittent bolus feeding3. Continuous feeding
Bolus feeding:Administered using a syringe/feeding reservoir Infused over a period of timeTolerance is dependent on the functional
ability of the gutGenerally, the px is fed a vol of 250-400ml of
formula-5-8x/dayAllow px greater freedom/movement between
feeding timesAssociated with high incidence of
complications: Nausea Vomiting Diarrhoea Abdominal distension & cramps Aspiration
Intermittent bolus feeding:Administered by slow gravity dripEach feeding is given over 30 min every 3-4
hrsTolerance is dependent in the functional ability
of the gut Initiation of feeding with 50 ml of isotonic formula
(<30ml/min) every 3-4 hrs Progression of feeding regime with additional 50 ml
every 8-12 hrs as tolerated
Generally, prescribed vol of formula 250-400 ml infused over a 20-30 min period 5-8x/day
Allow px greater freedom/movement between feeding times.
Complications can be similar to bolus feeding
Continuous feeding Utilised when bolus/intermittent feedings are not
tolerate/in critical ill patients/small bowel feeding
Usually pump assisted
Associated with reduced incidence of high gastric residual, GER and aspiration
Restricts px movement
Continuous tube feedingi. Initiation of tube feeding range from 20-
50ml/hrii. Progression of tube feeding range from 10-
20ml/hr every 8-24 hrs until the desired volume is attained
iii. the strength can be increased as tolerated.iv. If feeding is not tolerated-reduce the rate &
strength to previously tolerated level-gradually increase the rate & strength again
v. Avoid altering rate & strength at the same time
PART 2--NUTRITION SUPPORT FOR CRITICALLY ILL
ENERGY REQUIREMENT1. Haris Benedict Equation
Male REE = 66.47+13.75W+5.0H-6.76AFemale REE = 665.10+9.56W+1.85H-4.68A
W= wt in kg H = ht in cm A = age in years
2. Formula FAO/WHO/UNU (1985) Male 18 – 30 REE = 15.32W+679 30 – 60 REE = 11.2W+879 >60 REE = 13.5W+987
Female 18 – 30 REE = 14.7W+496 30 – 60 REE = 8.7W+829 >60 REE = 10.5W+596
3. Ismail et al.(1998)Men
18 – 30 years:BMR=0.0550(W)+2.480 MJ/d30 – 60 years:BMR=0.0432(W)+3.112 MJ/d
Women
18 – 30 years:BMR=0.0535(W)+1.994 MJ/d30 – 60 years:BMR=0.0539(W)+2.147 MJ/d
ACTIVITY AND STRESS FACTORS
Activity Factor=1.0 – 1.1 (bed rest)= 1.2 – 1.3 (very light) =1.4 – 1.5 (light)= 1.6 – 1.7 (moderate activity)=1.9 – 2.1 (highly active)= 2.2 – 2.4 (strenuous)
Stress Factor :
=1.1(mild malnutrition, postoperate no complication=1.2(mild illness confined to bed)=1.3(mild illness ambulatory)=1.2-1.3 (surgery major)=1.3-1.4 (trauma skeletal)=1.2 – 1.3(mild infection and stress)=1.4 – 1.5(moderate infection and stress)=1.6 – 1.8(severe hypercatabolic)=2.0 – 2.2(sepsis)=1.2 – 1.4(<20%BSA)=1.5 – 1.7(20 – 40%BSA)=1.8 – 2.0(>40%BSA)=1.2 – 1.3(Fracture)=1.4 – 1.5(respiratory or renal failure)=1.4 – 1.8(COPD)=1.5 – 1.6(Cancer with chemo or radiation,cardiac cachexis)
TYPES OF ENTERAL PRODUCTS
Standard/polymeric formulas Elemental Modular (Supplements) Condition Specific
Polymeric formula Composed of intact proteins,
disaccharides,polysaccharides, variable amounts of fat and residue
Require a functioning GIT for absorption and digestion
Category Characteristic Indication Products
Standard •Nutritionally complete•Provide 1 kcal/ml•Distribution:
50-60 % CHO10-15 % Protein25-30 % fat
Normal digestive & absorptive capacity
Ensure/Nutren Optimum/Osmolite
Fiber-suplemented
•Similar to standard formula except for fibre content•4 – 20g of dietary fibre/l
Constipation, diarrhoea
Jevity/ Nutren Fibre/Nutren Diabetic
Category Characteristic Indication Products
Concentrated Similar to standard formula except provide 1.5 – 2.0 kcal/ml
Fluid restriction Ensure Plus, Enercal Plus
Elemental formula Partially hydrolyzed protein
Characteristic Indication Products
Nutritionally completeUsually provide 1 kcal/ml
May contain glutamine
Reduced digestive & absorption capacity e.g. Crohn’s Disease, Short Bowel Syndrome, long term fasting with gut atrophy, post operative patients
Peptamen/AlitraQ, Elementum
Modular FormulasSingle nutrient supplement, nutritionally incomplete, usually low in electrolytes
Examples : Fat-MCT oil (Medium Chain Triglyceride) CHO- Carborie, Polycose (Glucose polymer) Protein- Myotein
Condition specific productsCondition Characteristic Indications Product
Metabolically stress
•Nutritionally complete•Provides 1.5 kcal/ml•High in protein: >20% kcal•May contain: arginine,nucleotides, omega-3 fatty acids
Polytrauma /post operative period (following major surgeries)
Perative
Hepatic Encephalopathy
•Protein content: high in BCAA, low in Aromatic Amino Acids
Hepatic Encephalopathy
Falkamin
Protein, electrolyte and fluid restriction
•Provides 2.0 kcal/ml•Low in protein•Low in phosphorous
Acute or chronic kidney disease not on dialysis
Suplena (NA)
Glucose Intelorance
•Nutritionally complete•Provides 1.0kcal/ml•Low in CHO: 35% of kcal•High in fat: 40-50% of kcal•Fibre supplemented
Hyperglycaemia :> 10mmol/L
Glucerna/ Nutren Diabetik/ Nutricomp®
Diabetic
Condition Characteristic Indications ProductCO2 retention •Nutritionally complete
•Provides 1.5 kcal/ml•High in fat: 55% kcal &•Low in CHO: 30% kcal
Chronic obstructive pulmonary disease with CO2 retention
Pulmocare
Electrolyte and Fluid restriction
•Provides 2.0 kcal/ml•Moderate in protein•Low in phosphorous
Acute or chronic renal failure requiring dialysis
Nepro/ Nutricomp® Renal
IMMUNE-ENHANCING FORMULAS
Have added “immune-enhancing” nutrients (arginine, glutamine, omega-3 fatty acids, nucleotides)
Results of research have been mixed
Multiplicity of active ingredients makes it difficult to control variables
Meta-analysis suggests that they might be most beneficial in surgical patients
Some evidence of harm in septic patients
EVIDENCE- BASED Glutamine should be added to standard formula
in: Burn & trauma patients
In Burns pt, the trace elements (Cu, Zn, Se) should be supplemented in higher dose
For the trauma patient, it is not recommended to routinely use immune-enhancing EN, as its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation.
Diet supplemented with arginine should not be used for critically ill pts.
FORMULAS FOR IMPAIRED GI FX: INFANT/CHILDREN
Protein Hydrolysate Pregestimil Alimentum
Peptide/ Elemental Neocate Peptamen Jr. Vivonex Pediatric Neocate advance
INITIATION OF FEEDING
Choose full strength, isotonic formulas for initial
feeding regimen.
Initiation and advancement of enteral formula in
pediatric patients is best done over several days
in a hospital setting using a flexible nutrition
plan.
INITIATION OF FEEDING- PAEDIATRIC
Continuous feeding Generally children are started
isotonic formula at a rate of 1-2 mL/kg/h for smaller children
1mL/kg/h for larger children over 35-40 kg. The rate is advanced based on tolerance by the child the goal of providing 25% of the total calorie needs on
day 1.
Bolus feeding 2.5-5 mL/kg can be given 5-8 times per day with
gradual increases in this volume to decrease the number of feedings to closer to 5 times daily.
INITIATION OF FEEDING-CHILDREN
Bolus feedings & gravity-controlled feedings started with 25% of the goal volume divided into
the desired number of daily feedings. Formula volume may be increased by 25% per
day as tolerated, divided equally between feedings
Pump-assisted feedings A full-strength, isotonic formula can be started
at 1-2 mL/kg/h and advanced by 0.5-1 mL/kg/h every 6-24 hrs until the goal volume is achieved
For preterm, critically ill, or malnourished children Use pump initial volume : 0.5-1 mL/kg/hour Advancing to 10-20 ml/kg/day
INITIATION OF FEEDING-ADULTS
Bolus feedings & gravity-controlled feedings full-strength formula 3-8 times per day increases of 60-120 mL every 8-12 hours as
tolerated up to the goal volume.
Pump-assisted feedings initiated at full strength at 10-40 mL/h and
advanced to the goal rate in increments of 10-20 mL/h every 8-12 hours as tolerated
PATIENT POSITIONING
Elevate the backrest to a minimum of 30º-45º, for all patients receiving EN unless a medical contraindication exists. Eg.unstable supine, hemodynamic
instability, prone position
If necessary to lower the Head-to-bed (HOB) for a procedure or a medical contraindication, return the patient to HOB elevated position as soon as feasible.
FLUSHES-PRACTICE RECOMMENDATIONS
Flush feeding tubes with 30 mL of water every 4
hours during continuous feeding or before and after intermittent feedings in an adult patient
flush the feeding tube with 30 mL of water after residual volume measurements in an adult patient
Flushing of feeding tubes in neonatal and pediatric patients should be accomplished with the lowest volume necessary to clear the tube
MEDICATION ADMINISTRATION
Do not add medication directly to an enteral feeding formula.
Avoid mixing together medications intended for
administration through an enteral feeding tube to reduce risks of:physical and chemical incompatibilities,tube obstructionaltered therapeutic drug responses
Dilute medication appropriately prior to administration.
REFEEDING SYNDROME
Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding.
These complications are often worsened by overfeeding or by use of aggressive repletion.
PHYSIOLOGIC CHANGES OCCUR DURING REFEEDING
Intracellular mineral depletionHypophosphatemiahypomagnesemia,Hypokalemiabody fluid disturbances (“refeeding
edema”)vitamin deficiencies (eg, thiamine)
lifethreateningcardiac arrythmiasrespiratory arrestCongestive heart failure
CONSEQUENCES OF ELECTROLYTE ABNORMALITIES
Electrolytes Consequence PO4 Acute ventilatory failure
Arrythmias Confusion Congesive heart failure Lethargy, weakness Rhabdomyolysis
K+ Arrythmias Cardiac arrest Constipation / ileus Polyuria / polydipsia Respiratory depression Weakness
Mg2+ Anorexia Arrythmias Confusion Diarrhoea / constipation Weakness
PATIENTS AT HIGH RISK OF REFEEDING
Patients with any of the following: BMI < 16 kg/m2
Unintentional weight loss >15% within the last 3-6 months
Very little or no nutrition for >10 days
Low levels of potassium, magnesium or phosphate prior to feeding
Patients with 2 or more of the following: BMI < 18.5 kg/m2
Unintentional weight loss >10% within the last 3-6 months
Very little or no nutrition for >5 days
A history or alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics
MONITORING FOR REFEEDING SYNDROME
Monitoring metabolic parameters prior to the
initiation of EN feedings and periodically during EN therapy should be based on protocols
Prevention of refeeding syndrome is of utmost importance
Px at high risk for refeeding syndrome and other
metabolic complications should be followed closely, and depleted minerals and electrolytes should be replaced prior to initiating feedings.
Patients at risk of developing refeeding syndrome
should be identified, electrolyte abnormalities should be corrected prior to the initiation of nutrition support.
Nutrition support should be initiated at approximately 25% of the estimated goal and advanced over 3-5 days to the goal rate.
Serum electrolytes and vital signs should be monitored carefully after nutrition support is
started
CHALLENGES IN NUTRITIONAL SUPPORT
1. Caloric requirement not met Under ordering by physician Reduced delivery Slow advancements
2. Gut dysfunction High residual volume (GRV) Nausea Vommiting Absent of bowel sound Diarrhea Aspiration
3. Procedure and diagnostic test require fasting
4. Lack of enthusiasm, personal bias and individual practice
THE RISK FACTORS FOR ASPIRATION
Sedation supine patient positioning the presence and size of a nasogastric tube malposition of the feeding tube mechanical ventilation, vomiting bolus feeding delivery methods poor oral health nursing staffing level advanced patient age
STRATEGIES TO OPTIMIZED DELIVERY & MINIMIZED RISK
1. Use feeding protocol2. Motility agent (eg. Prokinetic)3. Small bowel vs gastric feeding4. Body position5. Nutrition support practice
FEEDING PROTOCOL
e.g. Prospective evaluation before and after evidence based protocol introduction of EN in surgical pt.. Within 24 – 48 hrWith the protocol:
Inceased delivery of nutirentsShortened duration of mechanical ventilation
Decrease mortality
PROKINETIC AGENT: METOCLOPRAMIDE
IV administration of metoclopramide or erythromycin should be consider in pt with intolerance to EFE.g with high gastric volume
LEVELS OF GRV
Severity Definition Treatment
Mild <200 ml •Return GRV•Continue feeding
Moderate
200 – 500 ml •1st episode continue•2nd episode start prokinetic agent• 3rd episode reduce EN by half• 4th episode:
• Stop feeding• Place NJ tube• Start EN protocol again
Severe > 500 ml •Stop gastric feeding•Place NJ tube•Start EN protocol
Refer MNT pg 10 other assessment of tolerance
SMALL BOWEL FEEDING
Small bowel fed pt have improved energy delivery in some studies
Duodenal vs gastric feeding in ventilated blunt trauma ptImproved tolerance of EN and consequent faster achievement of desired calories
Kortbreek JB J Trauma
Small bowel vs gastric feedingMaybe associated with a reduction
in pneumonia in critically ill ptNo different in mortality or
ventilation daysSmall bowel feeding improves cal &
prot intake and is associated with less time taken to reach target rate of enteral nutrition.
NUTRITION SUPPORT PRACTICES
How should pt be tube fed after surgery?TF should be initiated within 24 hr after surgery
Sholud satrt with low flow rate (e.g 10 -20 (max) ml/hr)due to limited intestinal tolerance
May take 5 – 7 days to reach the target intake
Not consider harmful
ESPEN guideline 2006
NUTRITION SUPPORT PRACTICES
DO NOT…………..:1. Assemble feeding system on the pt’s
bed2. Top up fresh formula until the
formula hanging in the feeding bag has finished
3. Overfed patients: High calorie density formula
1.3 kcal/ml Perative 1.5 kcal/ml Pulmocare 2.0 kcal/ml nepro/enercal plus
OPEN VS CLOSED SYSTEM
Open System:Product is decanted into a feeding
bagAllows modulars such as protein and
fiber to be added to feeding formulasLess waste in unstable patients
(maybe)Shortens hang time Increases nursing timeIncreased risk of contamination
Closed System or Ready to Hang:Containers sterile until spiked for
hanging
Can be used for continuous or bolus delivery
No flexibility in formula additives
Less nursing time
Increases safe hang time
Less risk of contamination
More expensive than canned formula
Open System
Hang time 8 hours for decanted formula; 4 hours for formula mixtures
Feeding bag and tubing should be rinsed each time formula replenished
Contaminated feedings are associated with pt morbidity
Closed System
Hang time 24-48 hours based on mfr recommendations
Y port can be used to deliver additional fluid and modulars
May result in less formula waste as open system formula should be discarded p 8 hours
CONCLUSIONo Practice early enteral feeding
o Use strict protocols
o Modify preoperative preparation
o Identify & rectify tube displacement
o Consider tube placement post pyloric
o Alter method of feeding (routine cycling, smaller o volume, concentrated feeds)
o Works as Nutrition Support Team
o Continuous Nutrition Education
THANK YOU….Q???
TUTORIAL 1. Male, age 39, 189 cm tall. 91 kg body
weight, confined to bed and having burn of 40% TBSA and body temp is 39°. Calculate calorie req and plan a EN regimen.
2. Female, age 41, 160 cm tall. 67 kg body wt. confined to bed and ventilated. Diagnosed with COPD. Calculate cal req and plan for EN regimen through pump feeding
3. Pt with TPN, Patient on Nutriflex (peripheral) for three days after operation (75 ml/hr)
1. Calculate the calorie from the TPN2. How to manage the pt if dr plan to change to
EN