Specialized Nutritional Support PDF

REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 1 SPECIALIZED NUTRITIONAL SUPPORT Assess the gastrointestinal function....

REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 1 SPECIALIZED NUTRITIONAL SUPPORT Assess the gastrointestinal function. o If NORMAL, standard nutrients are given. o If COMPROMISED (there is obstruction or incomplete nutrients such as SPECIALIZED NUTRITIONAL SUPPORT proteins/carbohydrates), specialized formulas are given. Offered to patients who are malnourished or at risk of If there is nutrient tolerance, parenteral supplementation is needed. Then, becoming malnourished when it would benefit patients progress to enteral feedings. outcomes or quality of life However, going back in the assessment of functional GI tract. o Malnourished refers to when the body is not receiving the right amount o If NO, the GI tract is not functional, parenteral nutrition should be of nutrients. However, it is not necessarily a deficiency of all nutrients given. The nutritional assessment that requires parenteral nutrition are — if even one nutrient is insufficient, it can be considered malnourished. diffuse peritonitis, intestinal obstruction, intractable vomiting, ileus, Children who are 'buto't balat' may not necessarily be malnourished and intractable diarrhea, and gastrointestinal ischemia. those who are overweight can also be malnourished. ▪ For short-term, peripheral PN is given. Isotonic solutions are administered in smaller veins. Nutritional assessment should be based on the patient ▪ For long-term or fluid restriction, central PN is given. Hypertonic history and physical data solutions are administered in bigger veins. o Weight loss Once GI function returns, the patient will be switched to enteral nutrition. But, ▪ How long ago was the weight loss? if the GI function does not return, there could be an error in the medication, ▪ How much weight was lost? overdose, or there is a need to adjust the dose. o Dietary intake before admission CONTRAINDICATIONS o Disease severity ▪ either acute or chronic Intestinal obstruction o Comorbidities Ileus ▪ presence of diabetes or macronutrient deficiency (Marasmus, o Unable to tolerate any oral intake because the force needed for the Kwashiorkor) food to be passed on to the large intestine is not sufficient. When a person eats, the natural movement of the digestive system is not enough o Function of the gastrointestinal tract to move the food to the large intestine. ▪ different kinds of nutritional support Specialized nutritional support is supposed to improve the nutritional value of Peritonitis the ingested food and tailor it to the patient’s preference, abilities, and o Inflammation of the peritoneum. This restricts any movement for the schedule for them to complete their nutritional needs every day. internal organs. Bowel ischemia ENTERAL NUTRITION o There is lack of oxygen in the area. There is no sufficient blood flow Impaired digestion going to the intestines. Inability to consume adequate nutrition orally Intractable vomiting o inability to swallow Diarrhea Impaired digestion absorption and metabolism Severe wasting or depressed growth ENTERAL NUTRITION o Severe wasting – affects the muscle ▪ Example: During exercise, the first thing burned is fat. Next, if ADVANTAGES the patient becomes malnourished, muscle tissue is then broken Promotes growth and development of the gut down. If too much muscle is lost, this indicates severe wasting. o Patients are given nutrition via the enteral route to keep food moving Signs of malnutrition through the normal digestive tract, even though they don’t need to chew or take food orally. PARENTERAL NUTRITION Stimulates hormone secretion, motility and microbial If enteral nutrition has been maximized, we will provide parenteral nutrition. colonization Gastrointestinal incompetency Reduced feed tolerance Hypermetabolic state with poor enteral tolerance or Reduced risk of infection accessibility o this is the advantage of enteral nutrition over parenteral nutrition NUTRITIONAL ASSESSMENT PROCESS Avoids muscle atrophy Shorter hospital stay DISADVANTAGES Risk of NEC (Necrotizing Enterocolitis) Demands careful monitoring to ensure optimal nutrition is being delivered o With enteral nutrition, movement is restricted. Monitoring is necessary to ensure optimal nutrition as there is a tendency for the tube to curl up or for the stomach lining to rupture. ENTERAL NUTRITION SYSTEM In the Philippines, there is no standardized process. 1. Documentation (Screening and Assessment) o screening and assessment of the patient 2. Prescribe an EN regimen o usually, the dieticians or any healthcare provider assigned to the patient will prescribe the best EN regimen for the patient 3. Review the EN order 4. Procure, Select/Prepare, Label and Dispense EN Assess first if the gastrointestinal tract is functional. 5. Administer the EN o If YES, the GI tract is functional, enteral nutrition is given. This can be o administration is not part of the pharmacist anymore delivered through different routes: 6. Monitor and Reassess the patient ▪ long-term (gastrostomy, jejunostomy) 7. Assess the patient, their enteral access and recommend an ▪ short-term (nasogastric, nasoduodenal, nasojejunal) EN regimen  REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 2 Serum sodium Serum electrolyte o for possible electrolyte imbalances Wound healing o The wound healing capabilities of the patient should be assessed since there is incision and there is possible rupture of the stomach lining. o Example: If the patient is malnourished or sometimes even those who are not malnourished, the time for wound healing varies in every patient. Sometimes there is skin break down or the patient may be immunocompromised that’s why it is important to assess the wound healing capacity of the patient. Other medications ENTERAL FEEDING CYCLIC Not eating well during the day Usually administered overnight to free the patient from pumps during the day Used in patients with gastric or small bowel access BOLUS Bolus refers to rapid delivery. Used in patients in the long term care setting who have gastrostomy Feeding Delivery: 5-10 minutes Syringe is the only equipment used Used and repeated 4-6 times daily INTERMITTENT FEEDING Intermittent refers to delivery with interval or gap. Patients who cannot tolerate bolus This is an example of an enteral nutrition order. This contains the: specific formula Feeding Delivery: 20-60 minutes concentration (in kcal) Initiate at 150mL to 250mL per feeding until goal volume is other additives/medications achieved route of administration (feeding tube: nasogastric, gastrostomy, nasojejunal, Goal volume: 200-500mL per feeding (4-6 feedings per gastrojejunal, jejunostomy) day) method of administration (pump assisted, gravity-assisted, bolus, oral) INDICATIONS ENTERAL NUTRITION FORMULA Anorexia Carbohydrates Orofacial fracture Proteins Head and neck cancers Fats Neurological or psychiatric conditions that prevent oral Electrolytes intake Water Extensive burns Vitamins and Trace Elements Critical illness COMPLICATIONS STANDARD POLYMERIC FORMULA Improper tube placement Milk based blended meal preparation by the hospital or at home Clogged feeding tubes Nutritionally complete Aspiration Isotonic Diarrhea Provides 1 to 1.2 kcal/mL (adult); 20-30 kcal/oz (infant) Constipation o 1 fluid ounce = 29.57 mL Dehydration o 1 fluid drachm = 3.69 mL Hypernatremia Non-sweetened Sinusitis Given when there are no restrictions in the patient’s diet MONITORING Blood glucose concentration Head of bed elevation o this is to allow the natural flow of contents/nutrients to the stomach and to the entire gastrointestinal tract GI tolerance Weekly pre-albumin Ensure Gold is given to senior citizens for them to receive their daily nutrition. o albumin is a protein Diabetasol is given to diabetic patients and it is sugar-free.  REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 3 HIGH PROTEIN SPECIALTY Patients with high protein requirement Designed to meet specific needs o Example: athletes and bodybuilders o Diabetic For patients that are critically ill, with pressure sores and ▪ Example: Milk with very low in sugar or no sugar at all surgical wounds, and high output enterocutaneous fistula (Diabetasol, Glucerna). o Liver failure Beneficial for patients receiving propofol for sedation ▪ For patients with fatty liver, fatty or fine enteral nutrition o Since propofol is highly protein-bound, the patient could run out of components should be avoided. protein, so high-protein liquid nutrition is recommended. Usually, it is a high-protein liquid that is mixed with water. o Renal failure ▪ We should be careful since this is where all the ingested Allows protein requirement with minimizing risk of over formulation goes through. feeding PARENTERAL NUTRITION Also called hyperalimentation/hyperalimentary ADVANTAGES Early calorie intake o since it goes into the bloodstream Prevents catabolism o Catabolism – breakdown of complex substances Delivery of optimal nutrition o since it is straight into the veins, there is 100% bioavailability Reduced risk of NEC o opposite of enteral nutrition HIGH CALORIC DENSITY Concentrated with less fluid and electrolyte intake DISADVANTAGES Provides 2kcal/mL Risk for starving the gut o even though there are nutrients in the bloodstream, your stomach will Used for patients with kidney failure and congestive heart churn since there’s no food entering it disease Growth restriction It is similar to your calories and your proteins as standard polymeric o “In a way, mangagalawang yung gastrointestinal tract since they’re not formulation but with lesser fluid since it is needed to be concentrated. there pero kumakain ka” Expensive ELEMENTAL Infection risk Contains protein and/or fat component that are hydrolyzed Cholestasis into smaller forms o blockage of the blood flow into the liver Contains high proportion of protein in the form of amino INDICATION FOR PARENTERAL SUPPORT acids and low amount of fat Nutritionally complete ADULTS Easier on the GI tract GIT absorption problems o compared to your standard polymeric formulation Cancer o no GI discomfort Pancreatitis May be beneficial for patients with impaired digestion or absorption Critical care o Standard polymeric formula is for patients with no diet restrictions (e.g. Perioperative PN patients with no hyperacidity or patients with no sugar limits). Hyperemesis gravidarum o However, for people with very sensitive gut, elemental is beneficial for o intense vomiting them. Eating disorder MODULAR PEDIATRICS Can be in powder or liquid form Inadequate nutritional requirements from EN Single macronutrient Non-functional GI tract o the example photo below is a protein (for athletes and bodybuilders) and is usually mixed in their protein shake With extracorporeal membrane oxygenation (ECMO) Not nutritionally complete requirement o since it is only a single macronutrient o For patients with ECMO, when given oximeter, the value of their oxygen is 94% below or 86-94% Added to patient’s food to provide supplementation o Normal oxygen levels: >95% or for others it is >98% Organ failure COMPONENTS OF PARENTERAL NUTRITION AMINO ACIDS Organic constituents of all protein Contains amino group and carbonyl group Body’s primary source of nitrogen Provides 4 kcal/g  REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 4 EXAMPLE Macronutrients Normal range Usual doses Maximum (kcal/ kg/ day) (kcal/ kg/ day) (g/ kg/ day) Aminosteril 6% Calories 20-35 20-30 Aminoplasmal 10% Stable: 70-85% 7 4-5 mcg/kg/min Glucose of non-CHON 4-5 Critical illness: calories mcg/kg/min