1. Nutrition Support zDelivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status zTwo types: enteral – delivery of nutrients into GI tract through a tube parenteral – delivery of nutrients into blood steam intravenously

2. Why enteral support is thought to be better (than parenteral) zBy putting the nutrients into the gut, the gut mucosa keeps toxic substances from getting into the bloodstream & causing sepsis 1.GALT (gut associated lymphoid tissue) is part of immune system – provides 70% of body antibodies & contains lymphocytes 2. Maintain healthy bacteria in gut 3. Can give probiotics (lactobacillus) 4. Can give prebiotics (fiber & fructooliogosaccharides FOS s)

3. Enteral Feeding: indications for use zimpaired food ingestion: dysphagia, unconscious, fractured mandible, respiratory failure, inability to suck (premature infants) zimpaired digestion of whole (intact) foods: chronic pancreatitis, Crohn’s disease, short bowel syndrome zcannot meet nutritional requirements: major burn, trauma, anorexia nervosa, severe wasting

4. When the gut works, use it! zsafer - less risk of infection z less expensive z more easily done at home than parenteral Understand figure 23-1

5. Routes (access sites) for tube feeding depend: zHow long will feeding be needed? zRisk for aspiration of feeding into lungs zSurgical risk or no risk zSites: 1. Nasal gastric (NG) Nasalduodenal or Nasojejunal 2.Postpyloric- Gastrostomy-most common is PEG Jejunostomy- PEJ

6. Tubes in nasal cavity zNG - nasogastric: short-term 3-4 wks, pt has low-risk of aspiration (intact gag), normal digestion zNJ – nasojejunal (postpyloric): short-term, pt with high risk of aspiration, gastric or duodenal surgery or disease zX Ray to verify placement of a tube

7. Gastrostomy (G Tube): for long-term feedings zNeed functioning stomach & intestines zmore comfortable, for long term use > 4 weeks zPEG (Percutaneous endoscopic Gastrostomy) a procedure using endoscope to put special tube down into stomach & out abdominal wall zother “G” tubes surgically placed zmay use jejunum – jejunostomy, PEJ

8. Reasons not to use Enteral Support zileus - no bowel sounds zsmall bowel obstruction - SBO zsevere diarrhea or vomiting zrefusal of nutrition support by patient or through Advance Directive zhigh-output fistula (>500 cc/day) zacute pancreatitis zcan eat adequate amount by mouth

9. Choices for Enteral Formula 3 major types Is GI tract functioning normally? z YES = intact or polymeric formula z NO = hydrolyzed formula (monomeric)with polypeptides or amino acids & some MCT oil zwhen disease specific formulas warrented: renal, diabetes, hepatic, pulmonary, severe stress & trauma

10. Immune Boosting Properties in Enteral Feedings Impact, Perative, Crucial (p 1233) zGlutamine: primary energy source for rapidly ÷ cells; increases T cell production zArginine: increases T cells zOmega-3-fatty acids: causes less inflammation in cells, increases N balance zNucleotides: used to form DNA

11. Enteral Formula Selection: other factors to consider zAge - special formulas for pediatrics zCaloric density 1 kcal/cc to 2 kcal/cc zProtein density of formula (g/liter) zNa, K, Mg, P content? zWould fiber be beneficial? zCHO sources in formulas: hydrolyzed corn starch, maltodextrin, soy fiber, corn syrup solids - all lactose-free

12. Enteral Formula Selection zOsmolality (size and number of nutrient particles in a solution). If high (600 - 900 mOsmol/kg) fluid drawn into gut  diarrhea zExample: Osmolite = 1.06 kcal/cc, 14% pro, 57% CHO, 29% fat, Cal:N 178, Osmol 300, 1887 cc to get RDA, 80% free water, casein & soy pro, maltodextrin, safflower, canola, MCT

13. Tube Feedings zat home, person with healthy immune system, could use home made blenderized tube feeding zwater is used to “flush” or clean the tube - this water is part of individual’s fluid requirement & given during the day

14. How are tube feedings given? 1.Continuous drip using a pump 2.Intermittent drip using a pump if person eats some food during the day tube feeding may be given at night 3. Bolus using gravity instead of pump; given as a bolus 4-6 bolus times/day

15. How is a patient on tube feeding monitored? zgastric residuals (checked by RN) zstool frequency and consistency zurine output adequate (I and 0)  change in wt  ↓ zNa, K, BUN, creatinine, glucose zalbumin or prealbumin, Ca, P, Mg zseen/charted by RD every 3-7 days

16. Complications of Tube Feeding zdiarrhea zhigh gastric residuals zconstipation zaspiration pneumonia – tube feeding into lungs zpt pulls out tube

17. Complications in patient on tube feeding zhyperkalcemia zazotemia (  BUN,  Cr due to  ECF) prerenal azotemia: BUN > Cr 10:1 zhyponatremia zhyperglycemia zhypoglycemia

18. How much tube feeding does one give? 1.Determine the number of kcal pt needs during nutrition assessment 2.Decide site for access & type of tube feeding needed 3.Kcal needed day kcal ÷ ml of feeding = cc needed/ 24 hrs Example: 1.use NG tube, Nutren 1.0 with fiber 2.pt needs 1629 kcal/day÷ 1.0 kcal/cc 3.1629 ÷ 24 (hr) = 68 cc/hr continuous drip

19. Parenteral Nutrition - indications for use GI tract is not functioning well enough to meet nutritional needs of patient so nutrients put in bloodstream intravenously examples: zsmall bowel resection zsmall bowel obstruction zlarge output fistula below enteral feeding site

20. Parenteral Nutrition – access sites (where it can go into the bloodstream) zCentral access: requires surgical placement of catheter in large, high blood flow vein (total parenteral solution TPN) zPICC line: “tunneled” catheter inserted in vein in arm; solution taken to high blood flow vein (TPN) zPeripheral access: catheter tip placed in vein in arm. Requires a more dilute peripheral parenteral solution. (PPN)

21. Solutions: CHO = D 15 zSupplied as dextrose: 10% to 35% 10%= 100 gm/L, 25% = 250 gm/L zdextrose = 3.4 Kcal/gm 1 liter of 10% soln=(100gm x 3.4Kcal/gm = 340 Kcal) zPPN- Peripheral Parenteral Nutrition is put into small (peripheral) vein so cannot use more than D 1o

22. Solutions: Protein = D 15 with 2.5% aa @ 60cc/hr zsupplied as aa both essential & nonessential: choices: 2.5, 4.25, 5% solutions (2.5% = 25 gm/L 4.25% soln = 42.5 gm/L) zprotein =4 Kcal/gm; often not be included in total Kcal z60 cc x 24 = 1.44 L x 25 g/L = 36 gms in 24 hrs & 144 kcal of prot z1.44 L x 150 gm/L = 216 g dextrose x 3.4 kcal/gm = 734 kcal in 24 hrs

23. Parenteral Nutrition Solutions: Lipids zSupplied as aqueous suspension of soybean or safflower oil with egg yolk phospholipids as the emulsifier. Glycerol is added to suspension. z2 levels of emulsions: 10% solution: 1.1 kcal/mL 20% solution: 2.0 kcal/mL

24. D 15 with 2.5% aa @ 60cc/hr and 10% IL at 11 cc/hr 11 cc/hr x 24 hr = 264 cc x 1.0 kcal/cc = 264 kcal/day Total kcal: 1142 Kcal from fat: 264 (23%) Kcal from CHO: 734 (64%) Kcal from prot: 144 (13%)

25. Parenteral Nutrition Solutions Guidelines for amounts of each to provide: zProtein: 15 - 20% of kcal zLipids: ~30% of kcal zCHO: 50-65% of kcal zElectrolytes, vitamins, trace elements: lower than DRI zFluid: 1.5 - 2.5 liters total zKcal: N ration: 125 kcal:1 gm N

26. Parenteral Nutrition Solutions zPrepared aseptically & delivered 2 ways: z“3 in 1” solution: pro,fat,CHO in one bag and 1 pump is used to infuse solution z2 bag method: pro & CHO in 1 bag & lipid soln in glass bottle; each is hooked up to pump; solutions enter vein together zGiven continuously or cyclic (8-12 hrs/day) zInsulin may be added to solution

27. Parenteral Nutrition Solutions: Selected Complications zMechanical: thrombophlebitis zInfection and sepsis of catheter site zGastrointestinal: villous atrophy zMetabolic: hyperlipidemia, trace mineral deficiencies, electrolyte imbalance, refeeding syndrome zRefeeding syndrome

28. Transitional Feeding zA process of moving from one type of feeding to another with multiple feeding methods used simultaneously zExamples: parenteral feeding to enteral feeding parenteral feeding to oral feeding enteral feeding to oral feeding

29. Transitional Feeding parenteral to enteral 1.Introduce enteral feeding – 30 cc/hr while giving parenteral 2.If tolerated, gradually ↓ parenteral while increasing enteral 3.Once pt can tolerate 75% of needs enterally, d/c parenteral Process is called a stepwise decrease

30. Transitional Feeding parenteral to oral and enteral to oral Use step-wise decrease method; wait until pt accepting 75% oral and then decrease parenteral or enteral method But may need to: Offer oral during the day & cycle other from 6pm - 6am in order to ↑ provide motivation & reestablish hunger patterns Some children & adults may continue on oral during the day and enteral at night

31. Nutrition Support z most effective when provided as a team: RD, RN, Pharm D in conjunction with MD zVarious substances being investigated for therapeutic effects z$$ so look for articles on cost-benefit zKnow patient wishes for use – living will and if there is an advance directive