SUPPLEMENTAL NUTRITION

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SUPPLEMENTAL NUTRITION

• PROS, CONS, AND CHALLENGES

Sue Kane, SA-C, Clinical Coordinator Applied
Medical Technology, Inc.
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Malnutrition

• As a general rule, enteral or parenteral feeding
  is advised when a patient is unable to eat for
  7-14 days or longer.
• Malnutrition is a common problem increasing
  morbidity and mortality of hospitalized patients
  and is often not recognized throughout the
  hospital stay. This may affect recovery from
  illness, surgery and trauma and can result in
  poor post operative results as well as wound
  healing and post operative complications.
• .

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Protein Malnutrition
Usually caused by inadequate nutrient intake in
conjunction with a stress response
Causes Chronic diarrhea, renal dysfunction,
infection, hemorrhage, trauma, burns, critical
illness
Results Marked hypoalbuminemia, anemia, edema,
muscle atrophy, delayed wound healing, impaired
immunocompetence
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Protein-Calorie Malnutrition
Typically in the emaciated, elderly and
chronically ill patient
Results Weight loss, reduced basal metabolism,
depletion of subcutaneous fat and tissue turgor,
bradycardia, hypothermia
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Risk Factors of Malnutrition

• Recent surgery or trauma
• Sepsis
• Chronic illness
• Anorexia/eating disorders
• Dysphagia
• Recurrent nausea, vomiting or diarrhea
• Pancreatitis
• Inflammatory bowel disease
• Gastrointestinal fistulas

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Consequences of Malnutrition

• Longer recovery time
• Impaired defenses and sepsis
• Impaired wound healing
• Anemia
• Impaired G.I tract function
• Muscle atrophy
• Impaired cardiac function
• Impaired renal function
• Impaired respiratory function
• Brain dysfunction
• Atrophic skin

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Benefits of early nutrition

• Less time on mechanical ventilation
• Reduce infections
• Better wound healing
• Shorter hospital stays
• Maintaining bowel mucosa integrity
• May support normal immune function
• Decrease translocation of gut bacteria

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OVERVIEW

• The gastrointestinal (GI) tract is the route by
  which the body is supplied with water,
  electrolytes, and nutrients
• There are many clinical conditions in which the
  GI tract is temporarily or permanently
  unavailable, not functioning, or damaged. In
  these situations, the patients health is
  seriously jeopardized. Accessing the GI tract
  can be done intravenously or by tube feeding.
  Tubes nasogastric (NG), nasojejunal (NJ),
  gastrostomy (G-tube), jejunal (J-tube), and
  gastrojejunal (GJ-tube) are used to provide the
  body with nutrition, perform gastric
  decompression, and to evaluate/treat GI bleeding.
  Each of these tubes has a specific insertion
  technique, specific advantages and disadvantages,
  and complications. This presentation will provide
  a basic review of the anatomy and function of the
  GI tract and discuss the use of gastric tubes for
  enteral nutrition. Specific radiologic techniques
  that are used for insertion will be discussed and
  described.

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Review of G.I. Tract

• The gastrointestinal (GI) tract is involved in
  providing the body with water, electrolytes, and
  nutrients. In order for this to happen, food must
  be transferred through the GI tract, there must
  be a secretion of digestive juices, there must be
  absorption of water, electrolytes, and nutrients,
  and each part of the GI tract is designed to
  carry out one of those functions.

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SUPPLEMENTAL NUTRITION

• Oral preferred method
• Intravenously (Parenteral) used primarily for non
  functioning GI tract
• Via tube (Enteral) Preferred because it
  facilitates maintenance of intestinal structure
  and function, improves immunity, and avoids
  catheter related complications associated with
  parenteral nutrition. Accepted to be safer,
  associated with better patient outcomes and more
  economical than parenteral.
• nasal
• enterostomy

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Gastrointestinal Access

• Nutrition
• Gastric Decompression
• Evaluating/Treating patients with
  gastrointestinal bleeding

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Parenteral vs.
Enteral

• Nasogastric - Nose to fundus of stomach. A
  catheter tip syringe or suction tube attaches.
• Nasoduodenal/Nasojejunal-Nose to 3rd portion of
  the duodenum or the Ligament of Treitz in the
  jejunum.
• Gastrostomy - Abdominal wall to the stomach.
• Gastrojejunostomy - Abdominal wall to the stomach
  and the tube is advanced into the jejunum. Has 3
  ports, 1 for the balloon, 1 for the gastric
  fluids to be removed, and 1 for nutrition and
  medicines to be administered directly into the
  jejunum.
• Jejunostomy - Abdominal wall to the jejunum.

• Catheter placed in vein in arm or chest
• Hickman catheter, Broviac, PICC line, single,
  double or triple lumen catheters

In the setting of a functional gut, enteral
feeding is preferred to parenteral options.
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Parenteral - PPN (Peripheral)/TPN (Central)
Advantages
Disadvantages/Complications

• Needed when GI tract is non functioning
• Non patent G.I. Tract prior to surgery
• Post gastrointestinal surgery
• Short Gut Syndrome - A condition in which the
  bowel is not as long as normal, either because of
  surgery or because of a congenital defect.
  Because the bowel has less surface area to absorb
  nutrients, it can result in malabsorption
  syndrome

• Catheter associated infections
• Air Embolism
• Circulatory overload
• Hyperglycemia
• Hypoglycemia
• Catheter Occlusion
• Pneumothorax (central line)
• Venous thrombosis
• Infection
• Fluid and electrolyte complications

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Enteral -Nasogastric Indications

• Intact gag reflex
• No esophageal reflux
• Normal gastric emptying
• Stomach uninvolved with primary disease

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Contraindications

• NG tube feeding is inadvisable in patients with
  basilar skull fractures, severe facial fractures
  especially to the nose and obstructed esophagus,
  esophageal varices, and/or obstructed airway.
• Intestinal obstruction
• Gastric bypass surgery

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Nasogastric feeding tubes NG
Advantages

• Nutrition
• Avoid general anesthesia
• Avoid surgical procedure
• Low incidence of complications
• Reduce abdominal distention
• Speeding up the return of bowel function.
• Decrease the chance of wound dehiscence and
  hernia post op
• Decrease the chance of wound separation and
  infection post op
• Easy tube insertion
• Larger reservoir capacity in stomach

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Disadvantages and complications

• Highest risk of aspiration
• Abdominal distention
• X-Ray or fluroscopy for confirmation of tube
  placement
• Suited only to short term (6 weeks)
• Esophageal perforation
• Intracranial placement of the tube patients
  with severe head trauma, maxillofacial injury

• Pneumothorax
• Diarrhea
• Fluid and electrolyte imbalances
• Hyperglycemia
• Nose bleed
• Sinusitis
• Tube migration
• Block easily
• Patient self conscious of tube

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Methods of checking tube placement

• Air insufflation and auscultation of the
  epigastrium
• Aspiration of gastric contents
• pH testing
• X-ray confirmation (most reliable way to
  determine position of tube)
• Tube should be marked with permanent ink at the
  point of entry after x-ray confirmation

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Nasojejunal tubes
Many clinicians believe that enteral nutrition
delivered to the small bowel is a better choice
than feedings delivered to the stomach, and will
place a NJ feeding tube. This type of feeding
tube is more difficult to place than a NG tube,
but its proponents say that it decreases the
risk of aspiration, may provide more calories,
and the feeding schedule will be subject to fewer
interruptions. Both the jejunum and the stomach
can be safely used to deliver calories, the
differences between the two types of tubes are
minimal, both can be effective, and the decision
as to which one to use depends on the skill of
the practitioner and the potential tolerance of
the patient.
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The NJ tube can be placed using an endoscope or
by using fluoroscopy. When choosing fluoroscopy
the practitioner must weigh the exposure to
radiation, the need for transport to the
radiology department, patient safety, and cost.
Some practitioners have reported success by
placing the NJ tube in the stomach and allowing
it to spontaneously move into the small bowel.
Magnetically guided tubes have also been used as
well such as the Cortrak System.
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Nasoduodenal/Nasojejunal Indications

• Gastroparesis or
• impaired gastric
• emptying
• Esophageal reflux

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Nasoduodenal/Nasojejunal
Disadvantages
Advantages

• Potential GI intolerance (bloating, cramping,
  diarrhea)
• May require endoscopic placement of nasoenteric
  tube
• Patient self conscious due to appearance of tube
• Tube displacement and potential aspiration
• X-Ray or fluroscopy for confirmation of tube
  placement
• Suited only to short term (6 weeks)
• Esophageal perforation
• Intracranial placement of the tube patients
  with severe head trauma, maxillofacial injury
• Pneumothorax
• Nose bleed
• Sinusitis

• Reduced aspiration risk compared to NG
• Nutrition
• Avoid general anesthesia
• Avoid surgical procedure
• Low incidence of complications
• Reduce abdominal distention
• Speeding up the return of bowel function.
• Decrease the chance of wound dehiscence and
  hernia post op
• Decrease the chance of wound separation and
  infection post op

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It is important to secure feeding tubes. The
incidence of accidental loss is high particularly
in the critically ill who often have altered
levels of consciousness.
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Nutritional support improves clinical outcomes.
Frequent tube dislodgement may prevent effective
enteral feeding. In a prospective study, 21
patients received NG feeding over 173 days. Only
46 of volume feed prescribed was delivered.
Each patient required between 2-11 tubes and
85.9 dislodgements were due to patient removal.
Less than half of EN patients achieve their
caloric goal Prospective audit Leeds Teaching
Hospitals NHS Trust/Faculty of Health,Leeds
Metropolitan University, Leeds, UK Nov. 2008
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Securing Nasal Feeding Tubes

• OPTIONS
• Tape Inexpensive
• Disadvantages Skin breakdown, uncomfortable,
  risk of nasal injury
• Suturing Inexpensive, more effective than
  tape
• Disadvantages Uncomfortable, potential damage to
  nasal septum if pulled by patient or clinician
• Bridling (old school) Effective, inexpensive
• Disadvantages Uncomfortable to place, difficult
  to place, securing tube is challenging
• Bridling (AMT Bridle) Easy to use, safe,
  comfortable, cost effective, FDA approved device

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Securement of feeding tubes
A New Method The AMT Bridle is an umbilical tape
system placed with magnets that attract in the
nasopharyx to deliver the umbilical tape through
the nares. The NG tube is then secure with the
umbilical tape in an appropriate size clip.

• An Old Method
• A red rubber catheter, usually an 8fr, was placed
  through the nares on each side, retrieved in the
  nasopharynx with forceps, tied together,
  advanced, and then tied around the NG tube.

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Clinical References Regarding Bridling of Feeding
Tubes

• Routine Bridling of Nasojejunal tubes is a safe
  and effective method of reducing dislodgement in
  the ICU. This simple practice can be performed
  with low morbidity and may improve enteral
  nutrition and reduce exposure to procedural
  complications.
• Christopher W. Seder, MD Randy Janczyk, MD NCP
  Nutrition in Clinical Practice 2008-2009 23 (6)
  651-654
• Nasal bridling decreases feeding tube
  dislodgement and may increase caloric intake in
  the surgical intensive care unit A randomized,
  controlled trial.
• Christopher W. Seder, MD William Stockdale, RN
  Linda Hale, RN Randy J. Janczyk, MD, FACS
  Critical Care Medicine 2010, Vol. 38 No.3
• "Use of Nasal Bridle Prevents Accidental
  Nasoenteral Feeding Tube Removal.
• Scott R. Gunn, MD, Barbara J. Early, RN Mazen S.
  Zenati, MD, MPH, PhD Juan Ochoa, MD, FACS JPEN
  Journal of Parenteral and Enteral Nutrition 2009
  33(1)50-54

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• IMPROVE OUTCOMES
• Optimize caloric intake
• Reduced risk of aspiration
• Reduce radiographic exposure
• Eliminate skin breakdown due to
• adhesives
• Delay PEG placement or
• conversion to TPN
• Reduce risks of reinsertion
• Pneumothorax
• Esophageal perforation
• Tracheal / Bronchial injury

• DECREASE COSTS
• Cost of x-ray or fluoroscopy
• Cost of extended length of stay
• due to sub-optimal nutrition
• Cost of new nasal tube, formula
• and supplies
• Cost of clinicians time to replace
• nasal tube

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Preventing blocked tubes
Routine flushing with warm water can prevent
clogging of feeding tubes. Acidic products can
cause proteins in formula to coagulate. You may
need to flush before and after administering
solutions. As an alternative, pancreatic enzymes
with sodium bicarbonate may be used. Check with
physician.
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Gastrostomy placed laparoscopically,
operatively, or percutaneously Indications

• Swallowing dysfunction and subsequent impairment
  of ability to consume oral diet
• Intact gag reflex no esophageal reflux
• Long term feeding normal gastric emptying
• Stomach uninvolved with primary disease
• Patients with an inability to ingest adequate
  nutrients to meet metabolic demands

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Percutaneous Endoscopic Gastrostomy (PEG)
Push or pull method using an endoscope under
local anesthesia and conscious sedation It is a
safer and more cost effective method than
surgical placed gastrostomies and has a lower
mortality rate May be replaced with low profile
device usually after 6 weeks
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Gastrostomy
Disadvantages/Complications
Advantages

• May be used immediately or within hours of
  placement
• may be used for long-term support
• may be used in presence of significant disease of
  upper GI tract (esophagus, stomach and duodenum)
• percutaneously placed tubes avoid risks of
  general anesthesia
• laparoscopically placed tubes allow patient to
  return home same day as placed
• Larger reservoir capacity in stomach

• Peritonitis
• Stoma care needed
• Gastric perforation
• Hemorrhage requiring transfusion
• Deep stoma infection
• Septicemia
• Aspiration
• Wound infection
• Peristomal leakage/skin excoriation
• Tube dislodgement
• Potential fistula after tube is removed
• Surgery needed for surgical gastrostomies

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Jejunostomy
A Jejunostomy tube provides nutritional support
with the tube placed directly through the
abdominal wall into the jejunum. It is
particularly useful in patients who are at high
risk of aspiration of feedings delivered to the
stomach, patients with non-functional stomachs,
patients with esophageal carcinoma or chronic
pancreatitis, and patients who have had a total
gastrectomy.
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Jejunostomy - Indications

• Long term feeding
• High risk of aspiration
• Esophageal reflux
• Inability to access upper GI tract
• Gastroparesis or impaired gastric emptying
• Gastric dysfunction due to trauma or surgery

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Jejunostomy
Advantages
Disadvantages

• Potential GI intolerance
• Stoma care needed
• Peritonitis
• Stoma care needed
• Hemorrhage requiring transfusion
• Deep stoma infection
• Septicemia
• Wound infection
• Peristomal leakage/skin excoriation
• Tube dislodgement
• Potential fistula after tube is removed
• Tube occlusion with small bore tube
• Surgery needed for surgical jejunostomies

• Reduced risk of aspiration
• Placed adjunctly with GI surgery
• No surgery needed for percutaneous endoscopic
  jejunostomy
• PEJ less costly than surgical jejunostomy

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Gastrojejunostomy tube
When gastroesophageal reflux is present there is
a high risk of aspiration of gastric secretions
and enteral feeding. In this case a G-J tube is
used to aspirate gastric contents and feed into
the jejunum. The G-J tube is placed into the
stomach and secured by a balloon. There is an
extension of the tube with holes that is guided
into the jejunum for feeding. There are two ports
located on the outside of the tube.
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Pros and Cons of Enteral Feeding Technique
Technique Description Pros Cons
Continuous feedings Administered continuously using infusion pump Minimize risk of aspiration from reflux or high residual volume Allow controlled feeding into small bowel Improves glucose control Requires ongoing monitoring May waste formula
Cyclic feedings Administered less than 24 hours/day using infusion pump Often used at night Allows controlled feeding Reduces time pt is connected to pump Benefits pts using oral nutrition during the day who need supplemental nutrition Requires staff time for set up May require more vigilance at night
Bolus feedings Administered by gravity over 5 minutes via syringe Preferred by home going pts receiving tube feeds Provides fast administration No infusion pump required Allow gastric rest between feedings More likely to cause adverse effects Can be used only to deliver feeding to stomach May require more staff time for feeding
Intermittent gravity drip Use feed bag via gravity drip over 20-30 minutes Faster than continuous and cyclic feedings Often better tolerated No infusion pump Allows gastric rest between feedings Cannot use for delivery in jejunum May require more staff time for set up and delivery
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Conclusion
Using a team approach, it is important to start
enteral feeding as early as possible. Providing
early feeding will result in the best outcome for
malnourished and critically ill patients
resulting in shorter hospital stays and improving
their overall health. Review patient goals daily
and use recommended interventions to avoid
complications.
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