implementing enteral nutrition therapy: enteral access
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Implementing Enteral Implementing Enteral Nutrition Therapy:Nutrition Therapy:
Enteral AccessEnteral Access
Objectives
• To describe the benefits of enteral nutrition therapy• To review indications and contraindications of enteral
nutrition• To describe access routes for enteral nutrition infusion• To describe the advantages and disadvantages of
various enteral access routes
Enteral Nutrition Therapy: Benefits
• Maintains gastrointestinal structure and function• Reduces translocation of toxins and possibly bacteria• Less expensive than parenteral nutrition therapy• Fewer complications
“If the gut works, use it.”
Enteral Nutrition: Indications
• Patients unable or unwilling to consume adequate nutrition to meet metabolic requirements alone or with assistance
• Complement insufficient intake or increased demand
Enteral Nutrition: Indications
Requires total or partial GI tract function•Anorexia•Apoplexy•Coma•Sepsis•Trauma/surgery •Transition from parenteral nutrition
Enteral Nutrition: Contraindications
Absolute
• Complete bowel obstruction• Severe small bowel ileus with abdominal distention• Complete inability to absorb nutrients through the GI
tract
Enteral Nutrition: Contraindications
Relative• Severe postprandial pain• Short bowel syndrome • Intractable vomiting• Severe diarrhea
Gastric Access
Gastric Route Preferred • Adequate gastric motility• Minimum risk of aspiration
Gastric Route Contraindicated• Delayed gastric emptying (gastroparesis)• High risk for aspiration
Gastric Access
Gastric Route Advantages• Normal reservoir for food• Easy access• Tolerates high osmotic loads• Tolerates intermittent feedings• Gastric acid destroys contaminants• Can be placed by nurses
Gastric Feeding Techniques
Nasogastric Tube
Short term
Manual or radiologic
placement
Gastrostomy
Long term
Endoscopic,radiologic, or
surgical placement
Rugeles S, et al. Universitas Medica 1993;34(I):19-23
Nasogastric Tubes
8 Fr, stylet,
opaquebolus, 45"
12 Fr,opaque, 36"
12 Fr,clear, 36"
Nasogastric Tube: Disadvantages
• Short-term use only• Higher risk for aspiration• Difficult to confirm position• Small bore• Nasopharyngeal trauma/irritation• Accidental tube displacement
Percutaneous Endoscopic Gastrostomy: PEG Tubes
Rigid Flexible
Minard G. Nutr Clin Prac 1994;9:172-182
Percutaneous Endoscopic Gastrostomy: Advantages
• The same as for surgical gastrostomy• No surgery / less invasive• Minimal sedation• Direct visualization• < 30 minutes to place tube• Lower costs
Percutaneous Endoscopic Gastrostomy: Placement Criteria
• Adequate passage for endoscope• Ease in identifying safe site• Ease in determining a safe tract• Functioning GI tract• Absence of ascites / morbid obesity
Stellato TA, et al. Ann Surg 1984;200:46-50Lee M, et al. Clin Radiol 1991;44:332-334
Surgical Gastrostomy
• Performed in operating room• Indicated when PEG is contraindicated or during other
surgical procedures• Requires general anesthesia and full surgical team• In observation during recovery• More expensive than PEG
Gastrostomy: Low-Profile Tube
Post-pyloric Access
Indications for post-pyloric route
• Patient at risk for bronchial aspiration, gastric reflux• Gastric feeding contraindicated
– Gastric motility disorders; e.g., gastroparesis– Upper GI tract condition; e.g., carcinoma, stricture, fistula
Post-pyloric Access
Montecalvo MA, et al. Crit Care Med 1992;20:1377-1387
Advantages
Allows earlier post-op feeding
Lower risk of aspiration
Disadvantages
Small bore tubes, prone to obstruction
Tubes can be dislodged into stomach
Difficult to maintain long term Potential for dumping syndrome Requires infusion pump
Post-pyloric Feeding Techniques
Gauderer MW, et al. J Pediatr Surg 1980;15:872-875
Short Term
Nasoenteric – Nasoduodenal – Nasojejunal
Long Term
Jejunostomy – Percutaneous endoscopic
jejunostomy or through the PEG tube
– Surgical jejunostomy
Nasal Access: Tubes
Nasogastric Nasoduodenal / Jejunal
Easy
Short term
Y-Port
Small bore
Weighted tip
Metal guidewire
Post-pyloric Enteral Nutrition: Indications
• History / risk of reflux or aspiration• Gastric motility disorders• Upper GI tract fistulae• Acute pancreatitis
Post-pyloric Enteral Nutrition:Advantages
• Easily accessible• Less invasive• Lower risk of aspiration• Manual, fluoroscopic, or endoscopic placement
Post-pyloric Enteral Nutrition:Disadvantages
• Placement can be difficult to achieve and maintain • Requires x-ray confirmation• Short term use only• Nasopharyngeal trauma / irritation• Small bore tube
Jejunostomy Feeding: Indications
• Feeding
contraindicated for upper GI tract
• Gastric motility disorders
• History / risk of reflux or aspiration
Nutrition by Jejunostomy: Disadvantages
• Small bore tube• Placement can be difficult to achieve and maintain• Difficult to maintain for long term
Percutaneous Endoscopic Jejunostomy
• Tube placed with or without existing PEG• Requires endoscopy• Placed distal to Ligament of Treitz
Bumpers HL, et al. Surg Endosc 1994;8:121-123
Nasal Access: Multilumen Tubes
Choosing the Feeding Site
Can the GI tract be used?
No Yes
Tube feeding for more than 6 weeks?
No Yes
Nasoenteric Tube
Risk for pulmonary aspiration?
YesNo YesNo
Nasogastric Tube Jejunostomy
Parenteral Nutrition
Enterostomy Tube
Nasoduodenalor nasojejunal tube
Gastrostomy
Summary
• Enteral nutrition should always be the first option considered
• Gastric access is the first choice• Use post-pyloric route if gastric access not possible• Nasogastric route should be used for short term
feedings• Surgical or percutaneous enterostomies should be the
choice for long term cases and for laparotomy patients
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