Transcript parenteral
Nutrition Support
Delivery of formulated enteral or
parenteral nutrients to maintain or restore
nutritional status
Two types:
enteral – delivery of nutrients into GI tract
through a tube
parenteral – delivery of nutrients into
blood steam intravenously
Why enteral support is thought to be
better (than parenteral)
By 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 FOSs)
Enteral Feeding:
indications for use
impaired food ingestion: dysphagia,
unconscious, fractured mandible,
respiratory failure, inability to suck
(premature infants)
impaired digestion of whole (intact)
foods: chronic pancreatitis, Crohn’s
disease, short bowel syndrome
cannot meet nutritional requirements:
major burn, trauma, anorexia nervosa,
severe wasting
When the gut works, use
it! safer - less risk of infection
less expensive
more easily done at home
than parenteral
Understand figure 23-1
Routes (access sites) for tube
feeding depend:
How long will feeding be needed?
Risk for aspiration of feeding into lungs
Surgical risk or no risk
Sites:
1. Nasal gastric (NG) Nasalduodenal or
Nasojejunal
2.PostpyloricGastrostomy-most common is PEG
Jejunostomy- PEJ
Tubes in nasal cavity
NG - nasogastric: short-term 3-4
wks, pt has low-risk of aspiration
(intact gag), normal digestion
NJ – nasojejunal (postpyloric):
short-term, pt with high risk of
aspiration, gastric or duodenal
surgery or disease
X Ray to verify placement of a tube
Gastrostomy (G Tube): for
long-term feedings
Need functioning stomach & intestines
more comfortable, for long term use > 4
weeks
PEG (Percutaneous endoscopic
Gastrostomy) a procedure using
endoscope to put special tube down into
stomach & out abdominal wall
other “G” tubes surgically placed
may use jejunum – jejunostomy, PEJ
Reasons not to use Enteral
Support
ileus - no bowel sounds
small bowel obstruction - SBO
severe diarrhea or vomiting
refusal of nutrition support by
patient or through Advance Directive
high-output fistula (>500 cc/day)
acute pancreatitis
can eat adequate amount by mouth
Choices for Enteral Formula
3 major types
Is GI tract functioning normally?
YES = intact or polymeric formula
NO = hydrolyzed formula
(monomeric)with polypeptides or
amino acids & some MCT oil
when disease specific formulas
warrented: renal, diabetes, hepatic,
pulmonary, severe stress & trauma
Immune Boosting Properties
in Enteral Feedings
Impact, Perative, Crucial (p 1233)
Glutamine: primary energy source for
rapidly ÷ cells; increases T cell production
Arginine: increases T cells
Omega-3-fatty acids: causes less
inflammation in cells, increases N balance
Nucleotides: used to form DNA
Enteral Formula Selection:
other factors to consider
Age - special formulas for pediatrics
Caloric density 1 kcal/cc to 2 kcal/cc
Protein density of formula (g/liter)
Na, K, Mg, P content?
Would fiber be beneficial?
CHO sources in formulas: hydrolyzed
corn starch, maltodextrin, soy fiber,
corn syrup solids - all lactose-free
Enteral Formula Selection
Osmolality (size and number of
nutrient particles in a solution). If
high (600 - 900 mOsmol/kg) fluid
drawn into gut diarrhea
Example: 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
Tube Feedings
at home, person with healthy immune
system, could use home made blenderized
tube feeding
water is used to “flush” or clean the tube this water is part of individual’s fluid
requirement & given during the day
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
How is a patient on tube
feeding monitored?
gastric residuals (checked by RN)
stool frequency and consistency
urine output adequate (I and 0)
change in wt ↓
Na, K, BUN, creatinine, glucose
albumin or prealbumin, Ca, P, Mg
seen/charted by RD every 3-7 days
Complications
of Tube Feeding
diarrhea
high gastric residuals
constipation
aspiration pneumonia – tube feeding
into lungs
pt pulls out tube
Complications
in patient on tube feeding
hyperkalcemia
azotemia (BUN, Cr due to ECF)
prerenal azotemia: BUN > Cr 10:1
hyponatremia
hyperglycemia
hypoglycemia
How much tube feeding does
one give?
1.
2.
3.
Determine the number of kcal pt needs during
nutrition assessment
Decide site for access & type of tube feeding needed
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
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:
small bowel resection
small bowel obstruction
large output fistula below enteral feeding
site
Parenteral Nutrition – access sites
(where it can go into the bloodstream)
Central access: requires surgical
placement of catheter in large, high blood
flow vein (total parenteral solution TPN)
PICC line: “tunneled” catheter inserted in
vein in arm; solution taken to high blood
flow vein (TPN)
Peripheral access: catheter tip placed in
vein in arm. Requires a more dilute
peripheral parenteral solution. (PPN)
Solutions: CHO = D15
Supplied as dextrose: 10% to 35%
10%= 100 gm/L, 25% = 250 gm/L
dextrose = 3.4 Kcal/gm
1 liter of 10% soln=(100gm x
3.4Kcal/gm = 340 Kcal)
PPN- Peripheral Parenteral Nutrition
is put into small (peripheral) vein so
cannot use more than D1o
Solutions: Protein
= D15 with 2.5% aa @ 60cc/hr
supplied as aa both essential &
nonessential: choices:
2.5, 4.25, 5% solutions (2.5% = 25 gm/L
4.25% soln = 42.5 gm/L)
protein =4 Kcal/gm; often not be included in
total Kcal
60 cc x 24 = 1.44 L x 25 g/L = 36 gms in
24 hrs & 144 kcal of prot
1.44 L x 150 gm/L = 216 g dextrose x 3.4
kcal/gm = 734 kcal in 24 hrs
Parenteral Nutrition
Solutions: Lipids
Supplied as aqueous suspension of
soybean or safflower oil with egg yolk
phospholipids as the emulsifier. Glycerol is
added to suspension.
2 levels of emulsions:
10% solution: 1.1 kcal/mL
20% solution: 2.0 kcal/mL
D15 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%)
Parenteral Nutrition Solutions
Guidelines for amounts of each to provide:
Protein: 15 - 20% of kcal
Lipids: ~30% of kcal
CHO: 50-65% of kcal
Electrolytes, vitamins, trace elements: lower
than DRI
Fluid: 1.5 - 2.5 liters total
Kcal: N ration: 125 kcal:1 gm N
Parenteral Nutrition Solutions
Prepared aseptically & delivered 2 ways:
“3 in 1” solution: pro,fat,CHO in one bag and 1
pump is used to infuse solution
2 bag method: pro & CHO in 1 bag & lipid soln
in glass bottle; each is hooked up to pump;
solutions enter vein together
Given continuously or cyclic (8-12 hrs/day)
Insulin may be added to solution
Parenteral Nutrition Solutions:
Selected Complications
Mechanical: thrombophlebitis
Infection and sepsis of catheter site
Gastrointestinal: villous atrophy
Metabolic: hyperlipidemia, trace mineral
deficiencies, electrolyte imbalance,
refeeding syndrome
Refeeding syndrome
Transitional Feeding
A process of moving from one type of
feeding to another with multiple feeding
methods used simultaneously
Examples:
parenteral feeding to enteral feeding
parenteral feeding to oral feeding
enteral feeding to oral feeding
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
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
Nutrition Support
most effective when provided as a team:
RD, RN, Pharm D in conjunction with MD
Various substances being investigated for
therapeutic effects
$$ so look for articles on cost-benefit
Know patient wishes for use – living will
and if there is an advance directive