Transcript Dietary treatments for infantile colic

ENTERAL AND PARENTERAL NUTRITION
UPDATE
WITH THE NUTRITION CARE PROCESS
Suzanne Neubauer, PhD,RD,CNSC
Framingham State University
Overlook Health Center, Charlton, MA
January 31, 2013
Objectives
Identify proposed etiology based adult
malnutrition definitions.
 Using the AND evidence analysis library, state
best practices for enteral and parenteral
nutrition, including permissive underfeeding, BG
control, GI complications (aspiration, delayed
gastric emptying, diarrhea), administration
protocol.

Objectives
Calculate basic flow rates for enteral nutrition
considering interruption factors and fluid
needs.
 Calculate parenteral nutrition formulas,
including basic electrolyte considerations.
 Practice the nutrition care process for
enteral/parenteral cases, focusing on new
nutrition diagnosis and intervention
standardized language.

Objectives
Identify proposed etiology based adult
malnutrition definitions.
 Using the AND evidence analysis library, state
best practices for enteral and parenteral
nutrition, including permissive underfeeding, BG
control, GI complications (aspiration, delayed
gastric emptying, diarrhea), administration
protocol.

History for Etiology Based Malnutrition



only 3% of patients admitted to acute care settings in the US
are diagnosed with malnutrition (2009)
 primary ICD-9 code used: 263.9 Protein-Calorie
Malnutrition, NOS (not otherwise specified)
Suggest change current language to make it consistent with
an etiology based malnutrition diagnosis
CMS has also questioned the use of acute phase serum
proteins as primary diagnostic criteria for malnutrition
 Studies suggest there is limited correlation of acute phase
proteins with nutrition status
 Acute phase proteins may be a measure of inflammation
Adult Malnutrition:
Identify ≥ 2 of 6 Characteristics
6
Insufficient energy intake
 Inadequate food and nutrient intake or
assimilation: recent intake compared to
estimated requirements
 Weight loss
 Loss of muscle mass
 Wasting of the temples, clavicles,
shoulders, interosseous muscles, scapula,
thigh and calf

Adult Malnutrition:
Identify ≥ 2 of 6 Characteristics
7
Loss of subcutaneous fat
 Orbital, triceps, fat overlying the ribs
 Localized or generalized fluid accumulation
that may sometimes mask weight loss
 Diminished functional status as measured by
hand grip strength

Figure 1. Hypothetical relationship of Starvation-related Malnutrition (top graph) and Diseaserelated Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant
with changes in lean body mass.
Jensen G L et al. JPEN J Parenter Enteral Nutr 2010;34:156-159
Copyright © by The American Society for Parenteral and Enteral Nutrition
9
Figure.
Etiology-Based Malnutrition Definitions. Adapted with permission from reference (8): Jensen GL et al.
Malnutrition syndromes: A conundrum vs. continuum. JPEN J Parenter Enteral Nutr. 2009;33(6):710-716.
Characteristics Recommended for the
Diagnosis of Adult Malnutrition
Insufficient energy intake
 Weight loss
 Loss of muscle mass
 Loss of subcutaneous fat
 Localized or generalized fluid accumulation
that may sometimes mask weight loss
 Diminished functional status as measured by
handgrip strength

White JV, et al. JPEN J Parenter Enteral Nutr. 2012;36:275-283
Characteristics Recommended for the
Diagnosis of Adult Malnutrition




distinguish between severe and nonsevere
malnutrition.
continuous rather than discrete variables
should be routinely assessed on admission and at
frequent intervals throughout the patient’s stay in
an acute, chronic, or transitional care setting.
standardize the clinician’s approach to the
diagnosis and documentation of the presence or
absence of adult malnutrition.
Table 1. Academy/A.S.P.E.N. Clinical Characteristics That the
Clinician Can Obtain and Document to Support a Diagnosis of
Malnutrition White JV, et al. JPEN J Parenter Enteral Nutr. 2012;36:275-283
Clinical Characteristic
(1) Energy intake
Malnutrition is the
result of inadequate
food and nutrient
intake or assimilation;
thus, recent intake
compared with
estimated
requirements
is a primary criterion
Malnutrition in the
Context of Acute
Illness or Injury
Malnutrition in the
Context of Chronic
Illness
Malnutrition in the
Context of Social or
Environmental
Circumstances
Nonsevere
(Moderate)
Malnutrition
Severe
Malnutrition
Nonsevere
(Moderate)
Malnutrition
Severe
Malnutrition
Nonsevere
(Moderate)
Malnutrition
Severe
Malnutrition
<75% of
estimated
energy
requirement
for >7 days
≤50% of
estimated
energy
requirement
for ≥5 days
<75% of
estimated
energy
requirement
for ≥ 1
month
<75% of
estimated
energy
requirement
for ≥ 1
month
<75% of
estimated
energy
requirement
for ≥3
months
≤50% of
estimated
energy
requirement
for ≥3
month
Objectives
Identify proposed etiology based adult
malnutrition definitions.
 Using the AND evidence analysis library, state
best practices for enteral and parenteral
nutrition, including permissive underfeeding, BG
control, GI complications (aspiration, delayed
gastric emptying, diarrhea), administration
protocol.

Critical Illness Guidelines 2012: Enteral
Nutrition vs Parenteral Nutrition
14

If enteral nutrition (EN) is not contraindicated (e.g.,
by hemodynamic instability, bowel obstruction,
high output fistula, or severe ileus) then
recommend EN over parenteral nutrition (PN) for
the critically ill adult patient
 less septic morbidity and fewer infectious
complications (Grade I-strong)
 significant cost savings (Grade II-fair)
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
Critical Illness Guidelines 2012: Enteral
Nutrition vs Parenteral Nutrition
15
limited evidence that early EN vs. PN
decreases hospital length of stay (LOS)
 Grade II (fair)
 EN vs. PN impact on mortality has not been
demonstrated
 Grade II (fair)

http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
Critical Illness Guidelines 2012:
Initiation of Enteral Nutrition
16

Recommend EN be started within 24 to 48 hours following
injury or admission to intensive care unit
 If EN is not contraindicated (e.g., by hemodynamic
instability, bowel obstruction, high output fistula, or
severe ileus)
 Early EN (EEN) is associated with a reduction in
infectious complications in critically ill, adult patients:
Grade I (good)
 impact of EEN on mortality and length of stay (LOS) is
unclear: Grade II (fair)
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
17
Critical Illness Guidelines 2012:
Feeding Tube Placement
Small bowel placement vs gastric placement
 Benefits NOT demonstrated include
 ensuring adequacy of nutrient delivery
 reducing costs of medical care
 days on mechanical ventilation
 mortality

http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
18
Critical Illness Guidelines 2012:
Feeding Tube Placement

If a critically ill adult patient is mechanically
ventilated and requires EN
 recommend small bowel feeding tube
placement as studies suggest reduced
ventilator-associated pneumonia (VAP)
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
Critical Illness Nutrition Evidence Analysis Project,
2006: Postpyloric vs Gastric
19
Reduced residual volume
 Grade I: good
 Reduced aspiration pneumonia
 Grade III: limited
 Small bowel feeding tube may be useful in pts
with supine positioning, sedation and/or large
gastric residual volumes
 Grade IV: expert opinion
 Reduced mortality, LOS, and cost
 Grade V: not assignable

http://www.adaevidencelibrary.com/topic.cfm?cat=1035
Critical Illness Guidelines 2012:
Enteral Nutrition Energy Delivery
20
Actual delivery of >60% of EN goal within the
first week of hospitalization is associated with
fewer infectious complications in critically ill
adult patients
 Grade II (fair)
 Impact on mortality, hospital length of stay
(LOS), and days on mechanical ventilation is
unclear due to inconsistent results

http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
Enteral Feeding Interruption Factors

Mechanical
Complications
 Feeding-tube
displacement,
extubation,
occlusion
Supp.Line 1996;28:14

GI complications
 Abdominal
distention
 Delayed gastric
emptying
 Diarrhea
 Ileus
 vomiting
21
Enteral Feeding Interruption Factors

Therapies/
Interventions
 Airway management
 Bedside procedures
 Diagnostic procedures
 Medication administra-tion
via feeding tube
 Physical therapy
 Radiologic studies
 Surgery
Supp.Line 1996;28:14

Miscellaneous
 Agitation
 Coughing or
choking
 Nursing
limitations
 Pulmonary
aspiration
 Slow initiation
of feedings
22
Who Is at Risk for Aspiration?
23
Pts with trouble swallowing:
 Stroke
 Confused or debilitated adults
 Comatose
 Pts with tracheostomies
 Pts tracheally intubated
 Vagal disruption; trauma
 History of aspiration
 Severe gastroesophageal reflux

Who Is at Risk for Aspiration?
24





Pts with large bore feeding or suction tubes
 Use < 10 F to avoid compromise of LES
Gastric outlet obstruction
Gastroparesis
Postpyloric feeding ?? or jejunostomy
 Grade I for decreased residual volume (2006)
Patient position restrictions
 supine versus semirecumbent
Critical Illness Guidelines 2012:
Patient Positioning
25


recommend that critically ill adult patients be positioned
in a 30 to 45 degree head of bed elevation, if not
contraindicated
 during feed and 30 – 60 min after with bolus feed
Elevating head of bed decreases the incidence of
aspiration pneumonia and reflux of gastric contents into
the esophagus and pharynx
 Grade II (fair)
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
Causes of Delayed Gastric Emptying
26









Diabetes with neuropathy
Medications, chemotherapy, opiods
Gastritis
Paralytic ileus
Formula
 Very cold formula
 initial use of fiber-supplemented formula
 high-fat formula
Head injury/increased intracranial pressure
Mechanical obstruction
Sepsis
Aging gut
Check Residuals
27
Gastric
 Check every 4 – 8 hrs
 If > 500 ml (ASPEN guidelines) hold feeds for 1
hr and restart at last tolerated rate
If low flow rate/hr then residuals should be
approx < ½ the flow rate
 Small bowel: Usually do not check
 Difficult to aspirate contents from small bore
tube
 If gastric residuals then tube has likely slipped
back into the stomach

Critical Illness Guidelines 2012: Gastric Residual
Volume
28

Optimizing EN Delivery:
 Aspirate gastric residuals
 < 500 mL per ASPEN Guidelines
 When no overt signs of intolerance, N,V,
abdominal distention present
 Focus on serial trends not single measurement
 holding EN when GRV < 500 ml = delivery of less EN
 GRV does not correlate with risk for aspiration
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
Critical Illness Guidelines 2012: Use of
Promotility Agent
29

recommend the use of promotility agents
 if the critically ill adult patient has gastroparesis or
gastric residual volumes (GRVs) ranging from 200 to
500ml
 If there are no contraindications
 use of a promotility agent, e.g., metoclopramide, has
been associated with increased gastric emptying,
improved EN delivery and possibly reduced risk of
aspiration.
 Grade II (fair)
Critical Illness Guidelines 2012: Blue
Dye Use in Enteral Nutrition
30


recommend against adding blue dye to EN for detection
of aspiration in critically ill adult patients
the risk of using blue dye outweighs any perceived
benefit
 increases mortality risk
 Grade III (limited)
 presence of blue dye in tracheal secretions is not a
sensitive indicator for aspiration
 Grade III (limited)
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
JPEN 2002;26:S34-S42
31
JPEN 2002;26:S34-S42
32
33
Critical Illness Guidelines 2012: Fiber
34
Diarrhea may be reduced in adult critically ill
patients when guar gum is included in the EN
regimen
 The impact of other types of fiber on reducing
diarrhea is unclear due to variations in the
fiber combinations and amounts used in the
studies.

http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1
Critical Illness Guidelines 2012:
Hypocaloric, High Protein Feeding Regimen

Hypocaloric, high protein feedings for obese,
critically ill adults
 < 20 kcal per kg adjusted body weight and 2 g
protein per kg IBW
 promoted shorter intensive care unit (ICU) stays,
although total hospital length of stay (LOS) did not
differ
 Nitrogen balance was not adversely affected.
 Grade III (limited)
 effect on infectious complications, days on
mechanical ventilation, mortality and cost of care is
unsubstantiated
 Grade III (limited)
Critical Illness Guidelines 2012:
Immune-Modulating Enteral Nutrition


immune-modulating enteral formulas contain some
combination of arginine, glutamine, nucleotides,
antioxidants and fish oil
 Crucial, Impact, Optimental, Pivot 1.5
carefully evaluate for ICU patients without acute
respiratory distress syndrome (ARDS), acute lung injury or
severe sepsis
 some primary studies and meta-analyses with critically ill
populations have shown benefits
 in reducing infectious complications; Grade III (limited)
 hospital length of stay; Grade II (fair)
http://www.adaevidencelibrary.com/topic.cfm?cat=1035
Critical Illness Guidelines 2012:
Immune-Modulating Enteral Nutrition


IMF are not associated with
 reducing cost of medical care in critically ill
 Grade III (limited)
 Reducing days on mechanical ventilation in critically
ill
 Grade II (fair)
IMF may be associated with
 increased mortality in severely ill
 Adequately powered trials not conducted
 no effect on less severely ill
 Grade II (fair)
http://www.adaevidencelibrary.com/topic.cfm?cat=1035
Bolus Feed
38




Simple, low cost
Schedule feedings according to typical meal patterns
4 - 6 feedings/day administered for 30 – 60 min
 Start with ½ to 1 can per feeding
Typical feed is 240 – 480 ml/feeding
 2000 ml = 330 ml/feeding
6
 2000 ml = 500 ml/feeding
4
Continuous Drip Feeding Flow Rates
39



20 - 30 ml/hr in first 8 – 12 hrs for adults
Advance 10 – 20 ml every 4 – 8 hr until final rate
achieved
Final flow rate
 divide total daily volume by hours/day
 Total volume:
 2000 kcal
= 2000 ml total volume
1 kcal/ml formula
 2000 ml = 83 ml/hr flow rate
24 hrs
 2000 kcal
= 1667 ml total volume
1.2 kcal/ml formula
 1667 ml = 70 ml/hr flow rate
24 hrs
Continuous Drip Feeding Flow Rates
40

Small bowel continuous feeding
 Begin at 10 – 25 ml/hr
 Advance by 10 – 15 ml increments every 8 –
12 hours
Enteral Feeding Interruption Factors
41


How to determine goal rate compliance?
What to do if there is a compliance problem?
 2000 kcal
= 2000 ml total volume
1 kcal/ml formula
 2000 ml = 83 ml/hr flow rate
24 hrs
 2000 ml = 90 ml/hr flow rate
22 hrs
 2000 ml = 100 ml/hr flow rate
20 hrs