1. Enteral Nutrition: A Clinical Case Study using the Nutrition Care Process By Yingying Yip February 25, 2015

2. Outline  Introduction of enteral nutrition  Feeding tubes  Types of formula  Indications of EN  Complications  Dysphagia and Aspiration  Clinical Case Study  Nutrition Assessment  Nutrition Diagnosis  Nutrition Intervention  Nutrition Monitoring & Evaluation  Nutrition Follow-Up  Outcomes and Lessons

3. Enteral Nutrition  Provides nutrients into the GI tract using a tube  The tube is usually placed into the stomach, duodenum or jejunum via either the nose, mouth or the direct percutaneous route  Can be used in combination with oral and/or parenteral nutrition

4. Feeding Tubes  Nasogastric/Orogastric/Nasojejunal (NG/OG/NJ)  Temporary, <30 days  Gastrostomy (GT)  Long term  Done in the OR, more invasive via laparotomy  Percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEJ)  Long term  Endoscopically using transillumination to make incision

5. Percutaneous Endoscopic Gastrostomy  An endoscopic operation in which a feeding tube is placed through the abdominal wall and into the stomach  Allows nutrition, fluids, and medications to be administered directly into the stomach through the tube.

6. Enteral Formulas  Standard/polymeric  Contains intact nutrients: intact GI tract  Elemental  Completely hydrolyzed nutrients: malabsorption  Disease specific  For organ dysfunction or specific metabolic conditions: renal, trauma/burns

7. Indications for EN  “If the gut works, use it.”  Functional GI tract but oral intake may not be possible, adequate, or safe  Malnourished or at risk of malnutrition  Prolonged poor appetite  Impaired swallowing function  Conditions: anorexia, dysphagia, esophageal obstruction, esophageal dysmotility, reduced level of consciousness, short bowel syndrome(more than 100 cm of jejunum)

8. Complications  Necrotizing fasciitis  Intraperitoneal bleeding  Bowel perforation  Septicemia  Aspiration pneumonia  Buried bumper syndrome  Skin abscess  Cellulitis  Tube blockages  Tube falling out  Leakage of gastric contents

9. Dysphagia  Swallowing difficulty  Pain while swallowing, unable to swallow liquids and foods safely  Texture-modified diet and/or thickened liquids

10. Aspiration  A condition when foods or fluids go into the lungs instead of the stomach  Cough in order to clear the food or fluid out of their lungs   aspiration pneumonia Eating becomes a big challenge for people with dysphagia and people who are at risk for aspiration

11. CLINICAL CASE STUDY

12. Methodology  Data were collected from:  Patient’s medical record  Interview with patient  Discussed nutrition plan of care with physician and nurse  Initial nutrition assessment and follow-ups

13. Nutrition Assessment  JB: 92 year old male admitted with inability to take adequate oral nutrition, aspiration pneumonia, and features of hypovolemia  Underwent percutaneous endoscopic gastrostomy (PEG) tube placement and started tube feeding

14. PMH  Venous insufficiency, peripheral neuropathy, osteoarthritis, GERD, hyperlipidemia, atrial fibrillation, CAD, DM, osteoporosis, HTN, BPH

15. Nutrition Assessment – Food/Nutrition History  No known food allergies  Coughed when he ate for the past six months and avoided the dining room  Speech-language pathologist: allowed for small sips of water and possibly pureed diet for pleasure feeds post PEG placement

16. Nutrition Assessment - Physical Exam  Alert and oriented x3  Skin warm and dry  Abdomen soft

17. Nutrition Assessment - Social and Family History  JB - pharmacist, married  Daughter-in law - ophthalmologist  Son - rheumatologist  Expressed concerns over the procedure, types of tube feeding formula, and new lifestyle adaptations  Full resuscitation until conditions of advanced directives apply

18. Nutrition Assessment – Anthropometric measurement  Height: 69 in / 175 cm  Weight: 188.5 lbs / 85.7 kg  BMI: 28  IBW: 172 lbs / 78.2 kg

19. Nutrition Assessment – Nutrient Needs  Estimated energy needs: 20-25kcal/kg (20-25kcal) * (85.7kg) = 1700kcal - 2100kcal  Protein: 1 – 1.2g/kg  85-100 g protein / day

20. Nutrition Assessment – Biochemical Data Reference range 2/12/22/32/42/52/62/7 Reason for Abnormality Sodium (mMol/L) 135-145136138 139 141140 Potassium (mMol/L) 3.8 - 54.43.7 3.43.83.23.3 Decreased w/ diarrhea, K depleting diuretics Glucose (mg/dL) 70-90121126135114133113 DM Glucose POCT 93-189 mg/dLDM

21. Nutrition Assessment – Biochemical Data Reference range 2/12/22/32/42/52/62/7 Reason for Abnormality BUN (mg/dL)8-222923171519 20 Renal insufficiency, dehydration Creatinine (mg/dL) 0.4-1.21.31.11 1.21.11 Renal insufficiency, dehydration Phosphorous (mg/dL) 2.4-4.3 2.32.12 Possible refeeding syndrome Magnesium (mg/dL) 1.3-2.1 1.81.71.6

22. Medications ActionSide Effect/Nutrition Implication AmlodipineantihypertensiveDecrease Na may be recommended MetoprololantihypertensiveDry mouth, diarrhea, N/V AzithromycinantibioticDiarrhea SSIantidiabeticHypoglycemia

23. Medications ActionSide Effect/Nutrition Implication PPIAnti-ulcer, anti-gerdMay decrease absorption of Fe, vit B12 ZosynAntibioticdiarrhea KClElectrolyteGI irritation, N/V, diarrhea LasixDiureticDecrease K level in blood ProbioticBiotherapeutic agentHelp restore gut microbiome Prescribed during this hospital stay:

24. Initial Nutrition Assessment  NPO except for sips of water and medications for PEG placement  Poor PO intake PTA  Concerned about the volume per feed, calories, and delivery methods  JB preferred to start on bolus feeds  freedom of movement  Physician: expected JB to be d/c soon, d/c with bolus feeds, start with bolus feeds to assess tolerance  Basic metabolic panel, Mg, and Phos ordered

25. Nutrition Diagnosis - PES  Inadequate oral intake related to swallowing dysfunction as evidenced by poor PO intake PTA and patient NPO

26. PES – Inadequate oral intake  Goal: patient to meet nutritional needs via total enteral nutrition with tolerance  Intervention: Jevity 1.2 bolus feed via PEG: 2 cans at breakfast, 2 cans at lunch, 2 cans a dinner, 1 can 2-3 hours after dinner feed (total 7 cans daily); 100mL free water flush before and after each feed (200mL per meal, total 800mL free water flushes)  Total nutrition provided: 1995kcal, 93g protein, 2137 cc fluid

27. Nutrition Monitoring and Evaluation  Indicator: Enteral nutrition  Criteria: tolerate bolus feed at goal  Indicator: Electrolytes and renal profile  Criteria: WNL

28. NUTRITION FOLLOW-UPS

29. Nutrition Follow-up #1  JB w/ pleural effusion. Had diarrhea after each feed, refused feeding that morning. Formula changed to Osmolite 1.2. Free water flush decreased.  Nutrition dx:  1) Inadequate oral intake --- regressing  2) Altered GI function related to new PEG as evidenced by diarrhea after each feed  Nutrition prescription: Osmolite 1.2 bolus feed via PEG: 2 cans at breakfast, 2 cans at lunch, 2 cans a dinner, 1 can 3 hours after dinner feed (total 7 cans daily); 50mL free water flush before and after each feed (100mL per meal, total 400mL free water flushes) --- to provide 1995 kcal, 92g protein, 1765 mL free water

30. Formulas used in this case study Jevity 1.2 high-protein, fiber- fortified formula Osmolality, mOsm/kg H2O: 450 18 g fiber in 1000mL Osmolite 1.2high-protein, low- residue formula Osmolality, mOsm/kg H2O: 360 No fiber

31.  Thoracentesis done and 1200cc of fluid removed  Still had diarrhea  Space out the tube feed to improve tolerance  Administer a probiotic to balance the antibiotics  Decrease volume to 6 cans/day  Nutrition prescription: Osmolite 1.2 bolus feed via PEG: 1 can each on following schedule: 8am, 9am, 12pm, 1pm, 5pm, 6pm (total 6 cans/day); 75mL free water flush after each feed (75 mL per feed, total 450 mL Free water flush) --- to provide 1710 kcal, 80g protein, 1620 mL free water Nutrition Follow-up #2

32. Nutrition Follow-ups  #3  JB’s diarrhea had improved  MD ordered a test to rule out C. difficile infection  #4 Day of Discharge  Tube feeding order was canceled accidentally  Jevity 1.2 was sent and administered  Resent Osmolite 1.2

33. Outcomes  JB still had diarrhea at discharge but it had improved  Tolerated Osmolite 1.2 bolus feed, 6 cans per day with 75mL free water flush after each feed  Provide 1710 kcal, 80g protein, 1620 mL water

34. Lessons  Diabetes-specific enteral formula  Tube feeding complications  Continuous tube feed vs Bolus feed

35. References  Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., et al. (2009). Enteral Nutrition Practice Recommendations. Journal of Parenteral and Enteral Nutrition.  Botterill, I., Miller, G., Dexter, S., & Martin, I. (1998). Deaths after delayed recognition of percutaneous endoscopic gastrostomy tube migration. British Medical Journal.  Clearinghouse, N. I. (2010, October). Dysphagia. Retrieved from NIDCD: http://www.nidcd.nih.gov/health/voice/pages/dysph.aspx  Kirby, D. F., & Delegge, M. H. (1995). American Gastroenterological Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition. American Gastroenterological Association.  Lloyd, D., & Powell-Tuck, J. (2004). Artificial Nutrition: Principles and Practice of Enteral Feeding. Clin Colon Rectal Surg.  Lo¨ser, C., Aschl, G., Hebuterne, X., Mathus-Vliegen, E., Muscaritoli, M., Niv, Y., et al. (2005). ESPEN guidelines on artificial enteral nutrition - Percutaneous endoscopic gastrostomy (PEG). Clinical Nutrition.  Lynch, C., & Fang, J. (2004). Prevention and Management of Complications of percutaneous Endoscopic Gastrostomy (PEG) Tubes. NUTRITION ISSUES IN GASTROENTEROLOGY.  McMahon, M., Nystrom, E., Braunschweig, C., Miles, J., & Compher, C. (2012). A.S.P.E.N. Clinical Guidelines: Nutrition Support of Adult Patients With Hyperglycemia. Journal of Parenteral and Enteral Nutrition.  Stroud, M., Duncan, H., & Nightingale, J. (2003). Guidelines for enteral feeding in adult hospital patients. Gut.  http://www.summitgastro.com/endoscopic-procedures/peg-placement

36. Thank You! Any Questions?

37. Delivery Methods  Continuous  Uses a pump, low infusion rate  Ideal for inpatient, bedbound, high aspiration risk, acutely ill  Bolus  Uses a syringe, administer 240-480ml in 5-20mins  Ideal for those living at home  allows freedom of movement  Rapid infusion may cause GI intolerance

38. Complications  Diarrhea/constipation/nausea/vomiting  Distention/bloating/cramping  Aspiration  Dehydration/overhydration  Malabsorption/maldigestion  Hyperglycemia  Refeeding syndrome