Enteral and Parenteral Nutrition PDF

Enteral and Parenteral Nutrition Kanimolli Arasu, PhD Division of Nutrition & Dietetics Lesson Outcome  Describe indications for enteral nutrition (EN) and parental nutrition (PN)  Explain benefits of early feeding in critical illness  Describe route of feeding for EN and...

Enteral and Parenteral Nutrition Kanimolli Arasu, PhD Division of Nutrition & Dietetics Lesson Outcome  Describe indications for enteral nutrition (EN) and parental nutrition (PN)  Explain benefits of early feeding in critical illness  Describe route of feeding for EN and PN  Compare pro and cons of EN and PN  Drug interaction with EN & PN  Explain how to manage problems such as refeeding syndrome and other complications in nutrition support  Plan feeding regime based on:  nutrient adequacy  possible adverse reactions & contraindication What is Nutritional Support Therapy  The provision of enteral or parenteral nutrients to treat or prevent malnutrition.  Nutrition Support Therapy is part of Nutrition Therapy which is a component of medical treatment that can include  Oral  Enteral  Parenteral nutrition  to maintain or restore optimal nutrition status and health American Society of Parenteral and Enteral Nutritio  Indication for nutrition support Nutrition support should be considered in people who are malnourished, as defined by any of the following: a BMI of < 18.5 kg/m2 unintentional weight loss greater than 10% within the last 3–6 months a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months. NICE Clinical Guidelines 2017 Indication for nutrition support Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following: have eaten little or nothing for > 5 days and/or are likely to eat little or nothing for the next 5 days or longer have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism. NICE Clinical Guidelines 2017 Lesson Outcome  Describe indications for enteral nutrition (EN) and parental nutrition (PN)  Explain benefits of early feeding in critical illness  Describe route of feeding for EN and PN  Compare pro and cons of EN and PN  Drug interaction with EN & PN  Explain how to manage problems such as refeeding syndrome and other complications in nutrition support  Plan feeding regime based on:  nutrient adequacy  possible adverse reactions & contraindication Benefits of Early Enteral Feeding in Critically Ill  nutrition support therapy in the form of early EN be initiated within 24–48 hours in the critically ill patient who is unable to maintain volitional intake (ASPEN 2015) Enteral Feeding  Also called "tube feeding,"  enteral nutrition is a mixture of all the needed nutrients.  thicker than parenteral nutrition  Usually given through a tube into the stomach or small intestine but do also include oral feeds  Must have functioning GI track  GI track must be accessible Indications for Enteral Nutrition Oral intake is insufficient to meet nutritional needs due to a possible range of factors which may include fatigue, cognitive impairment, agitation, decreased motivation. Comatose patients on mechanical ventilation or with a severe head injury Dysphagia A neuromuscular disorder affecting swallowing reflex: Parkinson's disease, multiple sclerosis, cerebrovascular accident. Severe anorexia from chemotherapy, HIV, sepsis Upper GI obstruction esophageal stricture or tumor Conditions associated with increased metabolic and nutritional demands include sepsis, cystic fibrosis, and burns Mental illness like dementia Adeyinka et al 2022 Contra - Indications for Enteral Nutrition ASPEN consensus statement 2022 Oral Nutrition Supplement (ONS)  Provided in between meals  Added to food  Added into liquids  Complements poor oral intake Tube Feeding Administration Bolus Intermittent Continuous  Tube Feeding Administration Bolus Intermittent Continuous Rapid Feeding Pump delivery delivered required Formula via syringe 18-24 hrs delivered or pump via syringe < 10 mins  Nasogastric Pharyngostomy Radiologically Gastric inserted Oesophagostom gastrostomy y (RIG) Gastrostomy Oral Percuteneous Supplements Endoscopic Enteral gastrostomy (PEG) Nutrition Nasoduodena l Tube Feeding Surgical Duodenal gastrostomy Extended gastrostomy Nasojejunal Percutaneous Jejunal (PEJ) Direct access Surgical jejunostomy Managing the Patient Journey through Enteral Fin needle Nutritional Care, Clinical Nutrition (2006) 25, 187–195 Cathether Factors determining EN tube placement site  Length of therapy  Degree of aspiration risk  Risk of tube displacement  presence of normal or abnormal digestion  Planned surgical / endoscopic procedure  Administration and feeding schedule  Patient’s comfort & QOL  Nasogastric Tube Feeding (NGT) Characteristic Benefits  Short term (30 days) - When the tube can’t pass through the nose Benefits - reduce nasal discomfort - Can be given via bolus, intermittent, pump Initiation of Feedings after Placement of a Long-Term Enteral Access Device  Use a PEG tube for feedings within several hours of placement. Current literature supports ≤4 hours in adults and children. 2. Educate providers on the appropriate timing of use of the PEG tube postprocedure. 3. Review procedural documentation for time of PEG insertion. ASPEN 2018 Initiation of Enteral Feeding  Generally dilution of feeds not allowed  Initiate at full strength at slow rate and steadily advance Enteral Formulas  Enteral formulas designed to supply all needed nutrients when given in sufficient volume  Liquid diets intended for oral use or for tube feeding  Ready-to-use or powdered form  Designed to meet variety of medical and nutrition needs  Can be used alone or given with foods  Fig. 2 European e-Journal of Clinical Nutrition and Metabolism 2009 4e223-e225DOI: (10.1016/j.eclnm.2009.05.008) European e-Journal of Clinical Nutrition and Metabolism 2009 4e223-e225DOI: (10.1016/j.eclnm.2009.05.008)  Polymeric Monomeric Enteral Fibre Containing Formula Disease specific Categories Modular Rehydration Some examples of Oral Nutrition Supplements Fibre Disease Polymeric Monomeric Modular Containing Spesific Ensure Peptamen Nutren Nutren Carborie Nutren Alitraq Fibre Diabetic MCT oil Enercal Vivonex Jevity Glucerna Polycose Pentasure Semital Triple care Myotein Optimax Pulmocare Ceprolac lite Diabetesol Nepro Oxepa Pentasure DM Supplement D Pentasure Renal Reno-Pro Aminoleban These are just examples and the list is non exhaustive Polymeric Formulas  Formula containing intact nutrition ( protein, fat, and CHO) which require normal or near normal digestive and absorptive capacity and are complete with respect to vitamin, minerals, and trace elements at specified volume  Most are lactose free, gluten free, low viscosity 300- 500 mOsm/kg.  1 -2 kcal/ml  Requires patients to absorb whole nutrients  Whole protein nitrogen source  For patients with normal/ near normal GI function Monomeric Formulas  Formula have been hydrolyzed to contain short chain carbohydrate or simple sugar and peptides or amino acid.  Predigested nutrients  Free amino acids and/or short peptide chains  Has low fat content or high percentage of MCT, LCT, structured lipid  Contain partially or completely hydrolyzed nutrient (elemental).  The use of peptide based formula has been shown to be superior to free A.A in promoting greater nitrogen absorption in both healthy and disease gut.  They are used with condition of maldigestion or malabsorption. Fibre Containing Formula  Fiber-containing: containing a source of fiber; reportedly beneficial for prevention/treatment of altered bowel function in enterally fed patients  Soy polysaccharide is the most common fiber additive in enteral feedings; effectiveness in treating diarrhea in tube fed patients unproven  Soluble fiber (guar gum, oat fiber, pectin) may exert trophic effect on colonic mucosa and be useful in normalizing bowel function  Most enteral feedings in amounts typically used contain less than recommended fiber intake for adults (20-35 g)  Patients with impaired gastric emptying should not be fed fiber- containing formula into the stomach ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148 Calorie Densed Formulas  May be used in fluid-restricted or volume-sensitive patients  Useful for nocturnal feedings where nutrition must be delivered over brief time span  Calorie density ranges from 1.3 to 2 kcals/ml  Monitor fluid/hydration status Disease Spesific Formulas  Designed for patients with specific disease states.  Available for patients with respiratory disease, ARDS, diabetes, renal failure, hepatic failure, and immune compromise.  Enteral formulas are classed as medical foods, not drugs and are regulated differently  Diabetes Spesific formula  Diabetes Spesific formulas have many of the following ingredients in common:  lower CHO content than standard formula  higher proportion of complex carbohydrates that are slowly digestible to reduce blood glucose spiking  modified maltodextrin, starch, fructose, isomaltulose, and sucromalt, rather than the maltodextrin, starch, and sucrose found in standard formula  fat content enriched in unsaturated fatty acids, especially MUFA m  fiber content higher than in standard formula Based on this available evidence, the ESPEN expert group endorses the utilization of DFs for nutritional support of people with conditions such as diabetes, obesity or metabolic stress resulting from critical illness or surgery Karipidou 2018_ESPEN 2018 Types of Water Used in EN  A source of sterile water (eg, sterile water for irrigation) is considered best practice for the immunocompromised patient and for reconstituting powdered enteral formula. (APSPEN 2017)  Purified Water – sterile, solute-free, nonpyrogenic water that is free of any chemical ormicrobial contaminants  Distilled Water– water that has been vaporized  Tap Water– municipal or locally-available potable water that meets the Environmental Protection Agency’s (EPA) National Primary Drinking Water regulations (40 CFR Part 141-143)2 and is consistent with WHO guidelines for water safety.  NOT to use TAP water in Malaysia Parenteral Nutrition  Solutions in TPN Nutrients Solutions CHO Supplied as Dextrose, 10% or 35% Protein Supplied as amino acid; essential & non essential Fat Supplied as aques suspension of soyabean / safflower oil with egg yolk ohopholipids as the emulsifier Lesson Outcome  Describe indications for enteral nutrition (EN) and parental nutrition (PN)  Explain benefits of early feeding in critical illness  Describe route of feeding for EN and PN  Compare pro and cons of EN and PN  Drug interaction with EN & PN  Explain how to manage problems such as refeeding syndrome and other complications in nutrition support  Plan feeding regime based on:  nutrient adequacy  possible adverse reactions & contraindication Refer to Basic Pharmacology Lecture : Drug interaction in EN and PN Types of Patients whom are delivered Drugs via Enteral Feeding Tube  Intubated  Comatose  Inability to swallow oral medication  Limited IV access Lesson Outcome  Describe indications for enteral nutrition (EN) and parental nutrition (PN)  Explain benefits of early feeding in critical illness  Describe route of feeding for EN and PN  Compare pro and cons of EN and PN  Drug interaction with EN & PN  Explain how to manage problems such as refeeding syndrome and other complications in nutrition support  Plan feeding regime based on:  nutrient adequacy  possible adverse reactions & contraindication Complication of EN Administration Access problem problem Gastrointestinal Metabolic Psychological Monitoring gastric residual volume (GRV)  Performed by inserting a syringe into feeding tube & withdrawing gastric content & measuring volume Monitoring gastric residual volume  Measurement of GRV has traditionally been one technique used as an indicator for aspiration risk.  That is, no adequately powered studies have, to date, demonstrated a relationship between aspiration pneumonia and GRV.  Building a protocol around risk for aspiration could include several factors to reduce risk but not be solely based on measurement of GRV.  Studies suggest that “the elevated residual volumes by themselves have little clinical meaning and that only when combined with vomiting, sepsis, sedation, or the need for vasopressor agents does the correlation with worsening patient outcome emerge.  Elevated and increasing residual volumes may be a symptom of another underlying problem manifesting itself as delayed gastric emptying. If serial measurements reveal a change in GRV, other potential causes must be investigated rather than simply holding the enteral feedings. (McClave 2005) Monitoring GRV  Stable patients, especially those who have been fed by tube for long periods, do not need residuals checks regularly  Residue may contain more secretion and gastric fluid then formula In critically Ill………  GRVs not be used as part of routine care to monitor ICU patients receiving EN.  For ICUs where GRVs are still utilized, holding EN for GRVs