breiga pepping clinical dietitian dunedin...
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Breiga Pepping Clinical Dietitian Dunedin Hospital
Malnutrition State of nutrition in which a deficiency/excess (or
imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body forms or function and clinical outcomes
Protein Energy Malnutrition:• BMI <18.5 or weight loss of at least 5% in 6/12 (AND)
• evidence of suboptimal intake which has resulted in subcutaneous fat loss and/or muscle wasting
Malnutrition and overweight /obesity can co-exist
Regularly under-diagnosed and under-treated
Implications of Malnutrition Reduced ability to fight infection
Inactivity and reduced ability to work, shop, cook, self care • inactivity can lead to pressure ulcers and blood clots
Falls
Reduced QOL
Impaired mental health- depression, introversion, self-neglect
Impaired wound healing
Impaired treatment tolerance i.e. cancer treatments
Financial:
LOS, hospital admissions/readmissions, health care costs
Treatment interruptions
Artificial Nutrition Support Provision of nutrition support to meet nutritional
requirements in patients with inadequate oral intake
• sole source of nutrition
• supplementary nutrition
TPN/Enteral
• enteral feeding usually the most preferred method
• combination
Indications Severe malnutrition
• weight loss >10%, muscle wasting, peripheral oedema
Moderately malnourished but would be expected to develop significant malnutrition due to underlying disease
Well nourished but unable to commence normal feeding for considerable length of time (>3-4d)
Unable to meet nutritional needs with oral intake alone
Unable to eat/drink safely i.e. dysphagia
Contraindications for Enteral
Nutrition Major intra-abdominal sepsis
Total obstruction of gastrointestinal tract or
abdominal distension of unknown pathology
Malabsorption i.e. short bowel syndrome,
severe and intractable diarrhoea
Benefits of Enteral Nutrition
• Lower cost compared with TPN
• Enteral feeding shown can decrease risk of
bacterial translocation and therefore
bacteraemia
Goals of Enteral Nutrition• Achieve optimal nutritional status / hydration
• Correct significant nutritional deficiencies
• Achieve a satisfactory body weight
• Achieve normal metabolic parameters and fluid balance i.e. albumin, urea, creatinine, electrolytes, Hb.
• Allow for normal bowel function
• Facilitate the transition to oral intake when the clinical condition allows
• Reflect the wishes of the patient +/- their family
Enteral Nutrition Types of enteral nutrition:
NGT/ NJT/ PEG/ PEJ/ RIG
Stomach (NGT/PEG/RIG) preferable option
can do both bolus and continuous feeding
Small bowel continuous feeding only
NGT/NJT vs PEG/PEJ/RIG length of time enteral support required
patients condition
Other considerations
Possible Reasons for PEG • Neurological Diseases:
• Cerebrovascular
disease/stroke
• Motor Neuron disease
• Dementia
• Cerebral Palsy
• Multiple sclerosis
• Cancer
• Head and Neck / Oesophageal
• Burns
• Cystic Fibrosis
• Liver Disease
• Short bowel syndrome
• Chronic renal failure
• Head Injury
Contraindications for PEG Serious coagulation disorders
Hemodynamic instability
Sepsis
Sever Ascites
Peritonitis
History of total gastrectomy
Gastric outlet obstruction (if for feeding)
Sever gastroparesis (if for feeding
Interposed organs i.e. liver, colon
Marked peritonitis, anorexia nervosa
Limited life expectancy
Nutritional Assessment Anthropometry
height & weight
Biochemistry
Fluid & nutritional requirements
Food & fluid intake
Medications & interactions
Clinical condition CVA, cancer etc.
Social situation
Feeding Considerations
Aim of enteral nutrition support
sole source of nutrition vs supplementary nutrition
weight maintenance/gain/loss
Formula type and amount
Feed administration
Aspiration Risk
Flushes: how many and when
hydration / keep enteral feeding tubes clean and patient
Other Considerations: Refeeding Syndrome
Potentially fatal
Sever electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding
At risk if severely malnourished or very little or no food for more than 5 days
Common features sever fluid and electrolyte shifts → ↓P04, ↓K+, ↓Mg,
glucose abnormalities and thiamine and trace-element deficiencies
Other Considerations: Refeeding Syndrome
Identify patients at risk before starting enteral nutrition
Baseline electrolyte level + ongoing monitoring until the patient is metabolically stable
Feeding needs to be started cautiously
Serum levels do not need to corrected prior to commencing nutrition support- can be corrected during nutrition support
Medications Water flushes before and after is very important to
prevent blockages
Need to consider interactions with food, vitamins, electrolytes
medications that need to be given on an empty stomach
osmolality
sorbitol content
Medications: Commonly Used in Enteral Feeding
Anti Nausea / Motility agents: Metoclopramide Ondansetron Erythromycin
Laxatives Coloxyl with Senna Laxsol Lactulose Movicol
Antidiarrhoeals Loperamide Codeine Phosphate
Formulas Nutritionally complete
Lactose and gluten free
Range from 1-2kcal/ml
With or without fibre
Ready to hang
Closed system
1000ml or 500ml packs
Shelf life 24hrs after opening
12hrs if decanting
Formulas
Polymeric (whole protein)
protein in the form it is normally within the diet
Pre-digested (peptide/semi-elemental/elemental)
protein as smaller molecules i.e.; short peptides or free
amino acids
malabsorption / allergies
Disease Specific
diabetes / renal / fluid restriction /
Administration of Formula Bolus feeding
PEG / NGT only
Gravity / Syringe Push / Pump Bolus
usually over 5-6 feeds spread out over the day
Continuous feeding gastric and small bowel
via pump
feed continuously up to 24hrs a day
Combination bolus + continuous feeding
Administration of Formula Considerations: inpatient
patients clinical condition
rehab vs acute setting
staffing
treatments/procedures
Considerations: Discharge Planning rest home/hospital level care vs Home
supports available
patients ability and wishes aim to reduce impact of enteral feeding on QOL
Monitoring Gastric Residuals
when initiating NGT/PEG feeding
every 4hrs until feeding has reached goal rate
can only check if feeding into the stomach
Vomiting / Nausea anti nausea medication
rate/amount/type of feed
residuals
Monitoring Abdominal distension, cramping
temperature of feed
speed bolus feeds administered
gastric residuals
constipation
Monitoring Diarrhoea
medications e.g., sorbitol, magnesium, antibiotics
infection i.e. C Diff
resolving ileus
type of feed- osmolality/fibre
use of anti-diarrhoeal agents
Usual bowel habit
Temperature of feed
Administration rate of bolus feeds
Constipation fibre
fluid
medications- pain medications
decreased mobility
Monitoring Biochemistry
K, Ca, PO4, Mg- refeeding
urea, creatinine, Na, Albumin / CRP
liver function- detect overfeeding
vitamin D
Dietary intake compare intake with requirements and enteral intake
facilitate weaning from enteral to oral intake
food charts / diet history
Monitoring Fluid balance
important in heart, renal, liver patients where fluid restrictions may be needed
input and output
daily in acute setting- fluid balance charts
compare feed/fluid volume given with feed prescribed
Weight assess changes on hydration and body composition over time under/over feeding fluid shifts / changes in hydration weekly/twice weekly when starting or if hydration concerns monthly for an established home enteral feed
Monitoring
Clinical condition of patient
ensure feed tolerated
feeding route remain appropriate
changes in treatments
changes in lifestyle
Enteral to Oral Intake
50% of calorie requirements orally + 2 x high protein supplements
SLT
Food charts really important in assessing oral intake
Overnight feeding
Intermittent bolus feeding with oral intake
References Percutaneous endoscopic gastrostomy: indications,
technique, complications and management (World
Jrnl Gastroenterology: 2014 Jun 28:20(24)
ESPEN guidelines of artificial enteral nutrition-PEG:
Clinical Nutrition 2005
BAPEN Website
Guide to Refeeding Syndrome- Southern District
Health Board