Basics of enteral and parenteral nutrition

Surgical Nutrition Training ModuleLevel 1

Philippine Society of General SurgeonsCommittee on Surgical Training

Objectives

• To discuss the different feeding pathways for the surgical patients

• To define and discuss key points of enteral and parenteral nutrition

• To discuss the monitoring process and expected outcomes for surgical patients

Feeding PathwaysCan the GIT be used?

Yes No

Parenteral nutritionOral

< 75% intake

Tube feed

Short term Long term

Peripheral PN Central PNMore than 3-4 weeks

No Yes

NGT

Nasoduodenal or nasojejunal

Gastrostomy

Jejunostomy

“inadequate intake”

“Inability to use the GIT”

A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and

enteral nutrition in adult and pediatric patients, III: nutritional assessment –

adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.

EARLY ENTERAL NUTRITION

Early enteral nutrition: definition

• Enteral nutrition that is initiated within 24 – 48 hours following hospitalization, trauma, or injury

Zaloga GP. Crit Care Med 1999; 27: 259

Why early enteral nutrition?

• The normal and designed route for nutrient intake, digestion, and absorption

• Immunocompetence is a major function of the gastrointestinal tract

• Non-utilization of the gastrointestinal tract even on a short term basis leads to complications in critical care or geriatric patient management

• Cost-effective

Early enteral feeding: goal

• To maintain intestinal mucosal integrity

– Normal microvilli Height and number

– Normal intestinal barrier

– Intestinal mucosal immunity

Early enteral feeding: rationale • Provide nutrients required during metabolic

stress• Maintain GI integrity• Reduce morbidity compared with parenteral

nutrition• Reduce cost compared with parenteral

nutrition

Early enteral nutrition vs standard nutritional support on mortality

Comparison: mortalityOutcome: early enteral nutrition vs. control

Study Treatment n/N

Control n/N

Cerra et al 1990

Gottschlich et al, 1990

Brown et al, 1994Moore et al, 1994Bower et al, 1996Kudsk et al, 1996

Engel et al, 1997

Weimann et al, 1998

1/11

2/17

0/191/51

24/1631/16

7/18

2/16

1/9

1/14

0/182/47

12/1431/17

5/18

4/13

0.01 0.1 10 100Higher for control Higher for treatment

Ross Products, 1996 20/87 8/83

Mendez et al, 1997 1/22 1/21

Rodrigo et al, 1997 2/16 2/13

Atkinson et al, 1998 96/197 86/193

Galban et al, 2000 17/89 28/87

Heyland et al. JAMA, 2001

Pooled Risk Ratio1

ENTERAL NUTRITION

Enteral nutrition accessSTOMACH JEJUNUM

Nasogastric tube Nasojejunal tube

PEG PEJ

BUTTON

PLG

JET-PEG

PLJ

NCJ

PSJ

PFJ

PSG

PFG

Witzel, Stamm, Janeway

Loser C et al. ESPEN guidelines on artificial enteral nutrition – Percutaneous endoscopic gastrostomy

(PEG)

E: EndoscopicG: GastrostomyJ: Jejunostomy

L: LaparoscopicNC: Needle CatheterS: Sonographic F: Fluoroscopic

Access and delivery

Nasogastric tube

PEG tube

Nasoentericor jejunal tube

Gastrostomy

PEG placement 0

10

20

30

40

50

60

70

80

90

100

nu

mb

er

2000

2001

2002

2003

PEG placement, St Luke’s Medical Center

Post-pyloric feeding

Gauderer MW, et al. J Pediatr Surg 1980;15:872-875

Short Term

Nasoenteric

– Nasoduodenal

– Nasojejunal

Long Term (operative)

Jejunostomy – Percutaneous endoscopic

jejunostomy or through the PEG tube

– Surgical jejunostomy

Enteral Formulas – what type?

• Polymeric formulas (80-90%) • Commercial (preferred)

• Blenderized (If not critically ill, not severely malnourished)

• Oligomeric formulas

• Disease-specific formulas

• Modular formulas (concentrated protein and carbohydrate preparations)

Enteral nutrition delivery

Gravity Feeding Enteral Pump Delivered

Practical points: enteral nutrition• If intake is within the range of 60% to 70% start oral

supplement– Choose the product or preparation that meets all the daily

requirements• If oral intake is 50% or less

– You may give parenteral nutrition to supplement (good for a week – expensive, but more comfortable for the patient)

– Cost-effective: NGT• If tube feeding duration will exceed 2 weeks and you

are looking at long term (stroke or critical care) – gastrostomy is easier to maintain with lesser complications (aspiration)

Practical points: enteral nutrition

• If patient will undergo surgery and you doubt patient will be able to have adequate intake for longer term:– Place gastrostomy during the surgery

• If gastric function return is in doubt for more than a week:

• Gastrostomy with jejunostomy tube extension• Surgical Jejunostomy

• Main goal: adequate intake

Enteral formula: commercial vs. blenderized

Commercial Formulas Blenderized Formulas

Uniform contentsSterile

Low viscosityLactose freeDefined caloric density

Daily nutrient variabilityNon-sterile; high bacterial content and other pathogensHigh viscosityDoes not provide adequate caloric density

Gallagher-Alfred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50

Sullivan MM, et al. J Hosp Infect 2001;49:268-273

Bacterial contamination in standard tube feeds

Standard Feed: measured vs. expected

Sullivan MM et al. Nutritional analysis of blenderized diets in the Philippines (PENSA 1998)

Commercial formula

Commercial formula Natural food formula

Natural food formula

• Monitor according to hospital protocol (e.g., every 3-4 hours)

• Volume not to exceed 50% of the amount infused

Mentec H, et al. Crit Care Med 2001;29:1955-1961

Monitoring Gastric Residuals

PARENTERAL NUTRITION

Parenteral nutrition: Indications

• To avoid periods of starvation within 24 to 72 hours when oral or enteral intake are insufficient to achieve adequate intake in moderate to severe malnourished patients

• When unable to use the gut– Gut obstruction– Short bowel (intestinal failure)– High output enterocutaneous fistulae– Non-functional gastrointestinal tract

ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009; 28(4): 359-479.

• Gut can be used:– Ability to consume and absorb adequate nutrients

orally or by enteral tube feeding– Hemodynamic instability– *Ineffective and probably harmful in non-aphagic

oncological patients in whom there is no gastrointestinal reason for intestinal failure.

Contraindications to PN

.* Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009; 28(4): 448.

Types of parenteral nutrition

Central• Amino acids ( > 5%)• Dextrose ( > 20%)• Lipids• Includes vitamins, minerals,

and trace elements• Carrier of pharmaconutrients

like glutamine or omega-3- fatty acids

• Osmolality ( > 700 mOsm/kg H2O)

• Volume restriction

Peripheral• Total kcal limited by

concentration and ratio to volume being administered (usually delivers between 1000 to 1500 kcal/day)

• The current formulations can now deliver the daily requirements of macro and micronutrients

• Osmolality < 700 mOsm/kg• No volume restriction

Types of parenteral nutrition

• Central parenteral nutrition

• Peripheral central parenteral nutrition

PICC =peripherally inserted central catheter

Catheters

Subclavian catheter (3 ports) PICC line catheters

Types of parenteral nutrition

• Peripheral parenteral nutrition

Central venous access

• Allows delivery of nutrients into the superior vena cava or right atrium

• Osmolarity - traditional cut off > 860 mOsm/L• Catheter differences :

– According to duration of use– Various lengths, gauges, and number of ports– Catheters treated with antibacterials

• Nutrient infusion via a dedicated catheter lumen

• Pittiruti M et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters. Clin Nutr 2009; 28(4): 365-7.

Formulations

• 1 Optimal nitrogen sparing is shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours.

• The different forms of PN packaging and delivery:– 2 Individualized– 2 Compounded– 1,2 “All in One”

1. Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382.2. Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2nd ed 2005; 97-107.

Formulation / Delivery

Break seal

Individualized delivery system

“All in one” placed in multi-chambered bags

• cheaper• stable• none to minimum contamination

Compounding / clean rooms

Development phases of the PN container system

Safety issues

Three in one bags: longer

storage and less contamination

Protocols:1.Compounding2.Incorporation – additives3.Delivery (access, rates of infusion, infusion pumps)

In-lineFilters:1.Fat emulsions2.Three in one solutions3.Micro-precipitates

EN/PN monitoring parameters

Assessment

• Nutrient balance (calorie & protein intake)

• Body weight• Nitrogen balance• Plasma protein (albumin,

pre-albumin)

Metabolic

• Glucose• Fluid and electrolyte

balance• Renal and hepatic function• Triglycerides and

cholesterol

• Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992

• Ch 17: parenteral nutrition. Total Nutrition Therapy ver. 2, 2003; 311-12.

Key monitoring points

• Fluid balance – avoid fluid accumulation within 4-5 days post op

• Calorie balance• Gastric retention for enteral nutrition• Blood tests:

– BUN high – dialyze– High triglycerides – lower lipid flow– Hyperglycemia – insulin

• Weight once a weekJan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003

OUTCOME IS DEPENDENT ON THE MONITORING PROCESS

Feeding PathwaysCan the GIT be used?

Yes No

Parenteral nutritionOral

< 75% intake

Tube feed

Short term Long term

Peripheral PN Central PNMore than 3-4 weeks

No Yes

NGT

Nasoduodenal or nasojejunal

Gastrostomy

Jejunostomy

“inadequate intake”

“Inability to use the GIT”

A.S.P.E.N. Board of Directors. Guidelines for the use of parenteral and

enteral nutrition in adult and pediatric patients, III: nutritional assessment –

adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9SA-12SA.

Calorie, protein,

fluid balance

form

Nutrient monitor

form

Monitoring

DOCUMENTED OUTCOMES

Adequate intake in surgery patients

Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients

nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.

Nutrition team and intake

Llido et al. Nutrition team supervision improves intake of critical care patients in a private tertiary care hospital in the Philippines: report from

years 2000 to 2011 (for submission)

THANK YOU