Topic12 NS - Copy.pdf

SPECIALIZED NUTRITION SUPPORT The term NS includes food fortification, oral nutrition support, tube feeding & parenteral nutrition with the aim of increasing intake of macro &/or micronutrients. (ESPEN 06) NUTRITION SUPPORT NS FOOD ENTER...

SPECIALIZED NUTRITION SUPPORT The term NS includes food fortification, oral nutrition support, tube feeding & parenteral nutrition with the aim of increasing intake of macro &/or micronutrients. (ESPEN 06) NUTRITION SUPPORT NS FOOD ENTERAL PARENTERAL FORTIFICATION NUTRITION EN NUTRITION PN Normal food enriched with Uses the GI tract Bypasses the GI specific nutrients e.g. tract energy &/or proteins, minerals, vitamins TUBE ORAL NUTRITION FEEDING TF SUPPLEMENTS ONS Nasogastric, nasoenteral, Supplementary oral intake of dietary enterostomy, percutaneous food for specific medical purposes in tubes addition to normal food. Can be in liquid, powder, bar form, etc. 2 INDICATIONS FOR NS For patients who cannot meet their nutritional requirements by oral intake from normal food alone. At-risk group: pre- & post-operative patients patients with diseases of the GI tract, neurological problems, swallowing disorders patients with major trauma, burns or sepsis, catabolic diseases, cancers, in intensive care units the sick elderly, neonates, infants, children Patients with severe nutritional risk: weight loss > 10-15% within 6 months, BMI < 18.5 SGA Grade C serum albumin < 30 g/L with no evidence of hepatic/renal dysfunction 3 AIMS OF NS To prevent/minimise weight loss by ensuring adequate energy intake To achieve nitrogen balance, preferably positive nitrogen balance To provide essential nutrients in adequate amounts to support metabolic processes To maintain fluid balance to ensure normal renal, cardiovascular & respiratory systems functions 4 UNDERNUTRITION Poor clinical outcomes Failure of food Complications post-surgery supply/intake, deliberate Sepsis, wound infection, pneumonia fasting, disease  Length of stay Loss of body fat Loss of lean Undernutrition body mass muscle strength, Deficient energy or wasting protein Impaired immune intake/absorption (PEM),  Visceral response frequently accompanied by single/multiple protein Poor wound healing, micronutrient synthesis  risk of pressure sores deficiencies 5 ENTERAL NS Nutrition provided via the Gl tract - orally or through feeding tubes Why Choose Enteral Nutrition? IF THE GUT WORKS, USE IT! The enteral route is preferred in individuals who: have a functioning GI tract but cannot/will not eat to meet their nutritional requirements by food intake alone e.g. patients in hypermetabolic states, infections, sepsis, burns, trauma, multiple fractures, hyperthyroidism Serve additional foods at or between meals Provide enteral formulae to supplement the usual diet If still cannot meet requirements  tube feeding 6 ENTERAL NS – DETERMINE THE MOST APPROPRIATE 1. Type of formula Standard/polymeric Specialized/disease-specific Elemental/hydrolyzed/monomeric/pre-digested Modular 2. Feeding route Transnasal – nasogastric NG, nasoenteric (nasoduodenal ND, nasojejunal NJ) Enterostomy – gastrostomy, jejunostomy, percutaneous tubes (percutaneous endoscopic gastrostomy PEG, percutaneous endoscopic jejunostomy PEJ) 3. Formula delivery method Bolus Intermittent Continuous ENTERAL FORMULAE - TYPE Blenderized foods (home-made) Used in many developing countries cheaper commercial formulae not available Issues viscous, chunks of food may block tube add liquid when blenderizing  dilution  reduces nutrient density nutrient composition not precise need large bore tubes – rhinitis, esophageal reflux/strictures, esophagitis feed contamination – risky for immuno-compromised patients unsuitable for patients with digestion/absorption defects who need predigested formulae 8 ENTERAL FORMULAE - TYPE Commercial formulae Exact nutrient composition known/more reliable Less chances of contamination Easy to use, convenient A range of formulation to suit GI functional status of & disease-specific needs 9 ENTERAL FORMULAE - TYPES Standard/polymeric Intact proteins (from milk, soy), CHO (modified starches, glucose polymers, sugars) & fat Requires a functioning GI tract for digestion & absorption of nutrients Osmolality usually lower than “elemental” formulae Variations in flavors, fiber / lactose content, nutrient composition, % calorie from each macronutrient, For oral &/or tube feeding ‘Complete nutrition’ formulae will provide all essential nutrients in a specified volume 10 ENTERAL FORMULAE - TYPES Specialized/disease-specific Designed to meet specific nutrient needs of patients with particular organ dysfunction or metabolic abnormality. liver formulae: Hepatic-Aid II, Falkamin renal formulae: Nepro, Novasource Renal pulmonary formulae: Pulmocare, Oxepa diabetes formulae: Glucerna, Nutren Diabetes For oral &/or tube feeding Some provide ‘complete nutrition’ Generally expensive Effectiveness controversial 11 ENTERAL FORMULAE - TYPES Elemental/hydrolyzed/monomeric/pre-digested For patients with impaired digestive & absorptive functions Macronutrients have been broken down into simpler forms that require little, if any, digestion Protein: AAs or small peptides Fat: mono & diglycerides or MCT CHO: maltodextrins, oligosaccharides & glucose polymers For oral &/or tube feeding – has unpleasant taste Very expensive 12 ENTERAL FORMULAE - TYPES Modular Individual macronutrient preparations (modules) for patients who require specific nutrient combinations Vitamin & mineral mixtures usually added to help meet nutrient needs Sometimes, one or more modules may be added to other enteral formulae to adjust their nutrient composition Protein module: Myotein, Propass Fat module: MCT oil, Microlipid, Liquigen CHO module: SolCarb 13 WHICH FORMULA TO CHOOSE? Functional status of the GIT i.e. digestion & absorption capability Specific metabolic needs depending on medical condition - affects calorie level, level of fluid & electrolyte restriction Characteristics of formulae – energy density, macronutrient composition, osmolality, viscosity, other features e.g. fiber enriched, contains anti-oxidants, etc Higher energy densities: can meet energy & nutrient needs in a smaller volume of fluids, benefit those with high nutrient needs/fluid restrictions Fiber containing: may help normalize intestinal function, treat diarrhea & constipation, maintain blood glucose control; however avoid for those with acute intestinal conditions like pancreatitis, intestinal surgeries, etc. Enteral formulae with ~300 mOs/kg are isotonic, osmolality similar to blood serum. Elemental & nutrient dense formulae are hypertonic, can usually be tolerated, but when medications are also infused along with enteral feeds, osmotic load increase substantially, causing diarrhea Cost, taste, acceptance 14 WHICH FORMULA TO CHOOSE?  DIGESTION & ABSORPTION FUNCTIONAL IMPAIRED  SPECIFIC NUTRIENT NEEDS DEPENDING ELEMENTAL ON MEDICAL CONDITION * ADD MODULAR DISEASE-SPECIFIC PRODUCTS IF NO NECESSARY FORMULAE STANDARD FORMULAE HIGH ENERGY OTHER HIGH PROTEIN REQUIREMENTS * NORMAL ENERGY FIBER ENRICHED DENSITY, LOW RESIDUE * 15 FEEDING ROUTE Orogastric Transnasal Nasogastric NG Nasoenteric Nasoduodenal ND Nasojejunal NJ Enterostomy Gastrostomy/percutaneous endoscopic gastrostomy PEG if via percutaneous * A NONSURGICAL tubes* PROCEDURE, PERFORMED UNDER LOCAL ANESTHESIA, Jejunostomy/percutaneous endoscopic USING ENDOSCOPE & NEEDLE jejunostomy PEJ if via percutaneous PUNCTURE tubes* 16 FEEDING ROUTES Nasogastric tube Tongue Whole food by mouth Teeth Esophagus Gastrostomy tube Stomach Nasoduodenal tube Duodenum Jejunostomy tube Nasojejunal tube Jejunum Ileum Colon 17 FEEDING ROUTE Route Advantages Disadvantages Transnasal Does not require surgery or Easy to remove by disoriented patients NG incisions to place tubes Long term use may irritate the nasal ND passages, cause reflux esophagitis NJ Cosmetic issue (altered appearance social isolation, Ψ distress) NG Easiest to insert & confirm Highest risk of aspiration in placement, least expensive compromised patients Feeding can be given without Risk of tube migration to small intestine an infusion pump For short term use, 3-4 weeks (but has been used successfully for long term) ND, NJ Lower risk of aspiration in More difficult to insert & confirm compromised patients placement Allows for earlier tube Risk of tube migration to stomach feedings than gastric feedings Require infusion pump for delivery during severe stress 18 FEEDING ROUTE Route Advantages Disadvantages Enterostomy Allows the lower esophageal Tube must be placed by gastrostomy sphincter (LES) to remain closed, physician/surgeon, more costly / PEG reducing the risk of aspiration Risk of complications from jejunostomy Less tube displacement issues surgical insertion procedure, / PEJ More comfortable than transnasal less with percutaneous insertion Risk of infection at insertion site For long term use (peri-stomal infection) Site not visible under clothing Gastrostomy / Easier insertion than PEJ Modest risk of aspiration in PEG Feeding can be given without an high risk patients infusion pump PEG is the preferred choice for long term NS Jejunostomy / Lowest risk of aspiration Most difficult insertion PEJ Allows for earlier tube feedings procedure than gastrostomy during severe Most costly method stress Require infusion pump for delivery 19 FEEDING ROUTE Selection of route depends on: Anticipated duration of enteral feeding Short term: transnasal (NG, ND, NJ) Long term: enterostomy (PEG, PEJ) Degree of risk of aspiration High risk avoid transnasal which compromises LES function, especially NG Availability/functionality for certain routes To feed into the stomach (NG, PEG), must ensure no primary disease of stomach, no future procedure affecting gastric integrity Transnasal route not suitable in patients with nose/esophageal trauma/obstruction e.g. cancer 20 FEEDING ROUTE Gastric feedings (NG or gastrostomy/PEG) are preferred whenever possible More easily tolerated Less complicated to deliver as stomach will control the rate at which its content enter the small intestines Gastric feedings are avoided in patients who have high risk of aspiration Age > 60 – more likely to have multiple medical conditions, decreased swallowing ability, neurological deficits Impaired level of consciousness – from sedation or illness Gastroesophageal reflux – especially with delayed gastric emptying Neurological deficits – stroke, Parkinson’s To prevent aspiration Maintain head of bed > 300 Routinely verify tube placement Clinical assessment of GI tolerance (abdominal distension, discomfort, excessive residual) 21 ENTERAL TUBE PLACEMENT Nurses check NG tube placement by: aspirating gastric content & testing pH H+ with litmus paper – acidic (blue turns red) air insufflation & ascultation – injecting air through tube & listening for bubbles When in doubt → X-ray confirmation Nurses check NJ tube placement by: aspirating enteric content & testing pH with litmus paper – alkaline (red turns blue) When in doubt → X-ray confirmation 22 ENTERAL FEEDING TUBES Made of materials like polyvinyl chloride PVC, polyurethane or silicone Polyurethane softens at body temperature for patient comfort Available in a variety of diameters & lengths French scale 1Fr unit = 0.33 mm (outer diameter) Small bore tube usually 8-12 Fr, large bore tubes >14 Fr Gastrostomy tubes are short & wide (< 32 Fr) Jejunostomy tubes are long & thin (typically 7- 12 Fr) Radiopaque - allows confirmation of placement Weighted bolus (4g of tungsten) - ease of placement & inhibit tube migration 23 ENTERAL FEEDING TUBES 24 FORMULA DELIVERY METHOD Bolus Rapid delivery of a large volume of formula (250 – 500 ml) into the stomach in less than 20 minutes Intermittent Delivery of about 250 – 400 ml of formula over 20 - 60 minutes, several times a day (with a break of several hours before the next session) Continuous Slow, continuous delivery of formulae at a constant rate, usually over a 24 hr period 25 BOLUS FEEDING For patients who are clinically stable (not critically ill) with a functional stomach Uses a syringe to deliver 6 - 8 feeds every 3 - 4 hourly Convenient for both patient/caregiver, staff, frequently used rapidly administered does not require infusion pump, least expensive allows greater independence Often leads to complaints of abdominal discomfort, nausea, fullness & cramping. Risk of aspiration is greater. Not practical if high volume is required or patient needs to be fed round the clock 26 BOLUS FEEDING Feeds Syringe 27 INTERMITTENT FEEDING Best tolerated when delivered into the stomach (not intestines) Uses the gravity drip method or feeding pump 4-6 feeds/day Similar to usual pattern of eating, more physiologic, allow more freedom of movement  improved quality of life Due to the relatively high volume of formula delivered at one time, some patients may find it hard to tolerate Risk of aspiration may be higher than with continuous feeding 28 INTERMITTENT FEEDING Gravity Drip Method A gravity feeding bag set is filled with the appropriate amount of the patient's formula Feeding sets are equipped with Feeding bag roller clamps to control the flow rate - adjust the clamp as needed Hang feeding bag high enough Connect tubes to allow feeds to flow by gravity - lowering or raising the bag will also adjust the flow of the formula Roller clamp 29 CONTINUOUS FEEDING Used to deliver intestinal feedings (post-pyloric) Feeding Recommended for critically ill patients – slower bag delivery rate is easier to tolerate Requires a feeding pump – more costly & limits Feeding bag patient's freedom of movement tubing Feeding can continue at night allowing more Feeding pump intake of energy & nutrients 80 Not physiological - may elevate insulin levels  hypoglycemia, higher intragastric pH levels  promote bacterial growth Aspiration risk seems to be greatest overnight, thus overnight feeding may increase the risk of aspiration 30 CONTINUOUS FEEDING Feeding Pump Pump is electric/battery operated The feeding set is threaded through the pump, the rate of infusion is then programmed Higher accuracy in delivering expected volume Most pumps have alarm function - warning if flow of feed reduced/obstructed - saves nursing time Enables use of more viscous feeds 31 HANG TIME - ADULT EN Reconstituted powdered products