enteral and parenteral nutrition

7/21/2019 Enteral and Parenteral Nutrition

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Enteral and ParenteralNutrition

302

• Basics

Overview

What do Enteral and Parenteral Nutrition Refer To?

Enteral nutrition generally refers to any method of feeding that uses thegastrointestinal (GI) tract to deliver part or all of a persons caloricre!uirements" It can include a normal oral diet# the use of li!uidsupplements or delivery of part or all of the daily re!uirements $y use ofa tu$e (tu$e feeding)" The site of entry of the tu$e and tu$e types %ill $ediscussed under &enteral access&" Parenteral nutrition refers to thedelivery of calories and nutrients into a vein" This could $e as simple as

car$ohydrate calories delivered as simple sugar in an intravenoussolution or all of the re!uired nutrients could $e delivered includingcar$ohydrate# protein# fat# electrolytes (for e'ample sodium andpotassium)# vitamins and trace elements (for e'ample copper and inc)"There are many reasons for enteral and parenteral nutrition including GIdisorders such as $o%el o$struction# short $o%el syndrome# rohnsdisease# and ulcerative colitis* as %ell as certain cancers or in comatosepatients" While enteral nutrition is al%ays preferred %hen technicallypossi$le# some people may have a variety of medical issues that ma+e

the safe use of the GI tract difficult" ,lternatively# their calorie andnutrient needs may not $e met $y the current level of functioning of theirGI tract" That is %hen parenteral nutrition may $e needed to help anindividual remain hydrated and possi$ly to provide calories and othernutrients to allo% for gro%th and development or maintenance ofphysical %ell-$eing and function"

When Would a Patient Really Re!uire Enteral Nutrition?

When a patient has difficulty eating for %hatever reason# and if the GI

tract is %or+ing# then using this natural means for feeding %ould $eprefera$le to feeding $y intravenous means" .sing the GI tract is closer

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to normal and can help the immune system" ,n e'ample might $e apatient %ho has had a stro+e and no% has difficulty s%allo%ing (calleddysphagia)" The s%allo%ing may normalie over time or in someinstances may not return to normal %hich could put the patient at ris+ for

inadvertently s%allo%ing any solids and li!uids consumed into the lungs%hich could cause a severe pneumonia" /uring the short term# a patientli+e this might $e fed %ith a tu$e entering the nose" 0or longer use# atu$e entering the stomach from outside the a$domen (a gastrostomy)might $e appropriate"

What is 1eant $y and What are E'amples of Enteral ,ccess?

Tu$e feeding is nutrition provided through the GI tract via a tu$e#catheter# or a surgically made hole into the GI tract" ,s previously

mentioned# it is the preferred method of feeding %hen patients areuna$le to eat enough calories on their o%n" Enteral access devices arefeeding tu$es placed directly into the GI tract to deliver nutrients as %ellas additional fluids and often is a method for delivering medications(0igure 2)" Nasal or oral tu$es may $e placed at the $edside or %ithendoscopy" , nasoenteric tu$e means that the tu$e enters the nose andthe end of it may $e in the stomach# duodenum (first part of the smallintestine) or the 3e3unum (second part of the small intestine)"Gastrostomy and 3e3unostomy tu$es are inserted through the s+in(percutaneous) through a small incision on the upper a$dominal %all"This may $e done $y a Radiologist %ith 4-ray guidance# $y anEndoscopist via endoscopy# or surgically" The ta$le $elo% sho%s optionsfor enteral access feeding (Ta$le 2)" 5hort-term enteral nutrition isusually defined as use less than 6 %ee+s* long-term enteral nutrition isdefined as use for more than 6 %ee+s" 0or more specific information onpercutaneous endoscopic gastrostomy# please see the ,G patientresource of the same name"

Figure 1

Table 1

Enteral access

device

Length of

use

Pros Cons

Nasogastric tube Short- Easy to place, Not indicated if





(NGT; through the

nose)

term use variety of sies

available for patient

comfort

bleeding disorder,

nasal!facial fractures

and certain esophageal

disorders

"rogastric tube

(through the

mouth)

Short-

term use

#o$er incidence of

sinusitis than NGTs

Not tolerated for long

periods of time in alert

patients; tube may

damage teeth

Nasoenteric tube

(generally thought

of as a tube

beyond the

stomach)

Short-

term use

Smaller diameter

than NGTs and less

patient discomfort;

may be used in

delayed gastric

emptying

%ay be difficult to

position; smaller sie

tubes may ma&e

administration of some

medications difficult,

and an infusion pump

is needed

"roenteric tube

(postpyloric

feeding tube)

Short-

term use

Same as orogastric

tubes

Same as orogastric

tubes

Gastrostomy tube

(can be placed

radiologically,

endoscopically or

surgically)

Short-

term

use#ong-

term use

Easily cared for and

replaceable; large

sie tube allo$ for

bolus feeding, and

administration of

medications

'ompared $ith oral

and nasal route, this

techniue is more

invasive



emptying or are $eing fed into the small intestine" hoice of the deliverymethods for a particular person depends on the type of enteral accessdevice as %ell as the persons individual needs" Water flushes should $eadministered to prevent clogging and ensure ade!uate hydration"

0eeding tu$es should $e flushed %ith %ater $efore and after medicationdelivery and $efore and after every feeding or every 6 hours duringcontinuous feeding" 9ften a dietitian# nurse or home care company %illteach the patient ho% to prepare# administer# and monitor tu$e feeds" Inaddition# a home care company may $e availa$le to e'plain the supplyoptions availa$le and help to arrange for home supplies and e!uipment"

Who 1ay @enefit from Parenteral Nutrition?

,nyone %ho cannot%ill not eat# or cannot maintain their fluid andor

nutritional status $y oral eating or $y tu$e feeding may $e appropriate for intravenous nutrition" ,gain# the preferred route is $y using someonesGI tract# $ut this is not al%ays possi$le" The intravenous route is morecomplicated and e'pensive to do and is almost al%ays started in thehospital"

What ,re the 9ptions for /elivering Parenteral Nutrition?

Parenteral nutrition access options include central venous catheters%hich may include short term catheters %hich are tu$es that are put inplace in the hospital and generally removed prior to discharge and longterm options (such as tunneled 8ic+man catheters) located in the upperchest# peripherally inserted central catheters (PI) located in the upper arm# and ports implanted under the s+in usually in the upper chest %all"(5ee figures : and < $elo%)" 1any catheters are availa$le in multilumenversions to allo% for simultaneous infusion of multiple fluids andormedications" entral venous catheters are commonly used for patientsre!uiring %ee+s# months or years of therapy" , 8ic+man catheter is a$rand of catheter that is tunneled under the s+in and put in place eitherin a Radiology /epartment or in an operating room" , 8ic+man catheter

re!uires dressing care to $e performed $y the patient# a family mem$eror a 8ome are 5ervice" , PI is commonly used in patients %hore!uire therapy for a short duration# usually for several %ee+s to a fe%months" , PI may $e placed %hile in the hospital at the patients$edside# in the Radiology /epartment or rarely at home $y a speciallytrained registered nurse" /epending on the local protocol# a PI alsomay re!uire routine flushing %ith a drug called heparin to preventclogging and additional site care and also has a higher rate of thecatheter moving out of position than a 8ic+man catheter" Ports are often

used for patients re!uiring months to years of therapy and are commonlyused %here intermittent infusion therapy is needed such as cancer







chemotherapy" are of a port is needed only %hen the port is accessed"This is done $y cleaning the s+in $efore placing the special needle intothe port and monitoring of the port site closely" Ports allo% for people tomaintain their $ody image# and there are no e'ternal components that

may $e prone to damage %hen the port is not in use" Placement of aport usually occurs in an operating room or $y a Radiologist %ith 4-rayguidance"

Figure 2: Catheters Parenteral Nutrition ! Te"#orar$

Figure 3: Catheters Parenteral Nutrition ! %ong Ter"

What ,re the omplications of Parenteral Nutrition# and 8o% an

They $e Prevented or /ecreased?The most common complications associated %ith catheter placementinclude infection# clogging (occlusion)# and $rea+age" , strict infectioncontrol protocol is recommended regardless of the type of catheterplaced and includes the follo%ing7 hand %ashing# aseptic site and hu$care (%earing gloves# prepping site %ith topical antiseptics# etc")# portsteriliation $efore access# close monitoring of catheter site appearancefor redness or inflammation" atheter occlusion# or ina$ility to infuse asolution andor aspirate a $lood sample# may $e prevented $y flushing

the catheter to +eep it open" atheter occlusion may arise from $lood# IAfat solutions# or precipitates (a$normal crystal formation in a solution)and may $e treated %ith a declotting agent administered $y a RegisteredNurse" When a catheter is crac+ed# lea+ing# or $ro+en# the catheter must$e repaired or replaced as soon as possi$le" , catheter is clamped$et%een the e'it site and the $rea+ to prevent entrance of air or lea+ageof $lood"

Throm$osis ($lood clot) of a $lood vessel around an intravenouscatheter is another potential complication %ith intravenous therapy as

%ell as intravenous nutrition" 1any factors play a part in the clotting of avessel and different institutions may have special protocols for $othprevention and treatment"

an Parenteral Nutrition $e /one at 8ome?

8ome parenteral nutrition (8PN) re!uires a team of clinicians tosuccessfully manage and minimie the associated complications asdiscussed a$ove" 8ome parenteral nutrition may $e performed for manyconditions as a short-term therapy or as a long-term therapy" ,s the

parenteral nutrition formula is $eing ad3usted in preparation for dischargefrom the hospital# the patient and caregiver %ill receive education on









catheter care# operation of the infusion pump# parenteral nutrition set-upand disconnect procedures# maintenance of inta+e and output records#revie% of meta$olic complications# and contact num$ers for associatedpro$lems that may arise" ,ll patients are monitored closely for electrolyte

distur$ances %ith routine $lood dra%s to assure sta$ility on 8PN formulaand clinic visits" If a patient needs readmission to the hospital# thenutrition support team and home nutritional support clinician %ill often%or+ %ith the hospital team to provide continuity of care"

an I Wor+ While on Parenteral Nutrition?

There are many individuals %ho continue to %or+ and have very full andproductive lives %hile receiving parenteral nutrition" The maindeterminant %ill $e the degree of disease that caused the underlying GI

pro$lem that is left# as %ell as symptoms the patient is e'periencing"Each person needs to $e assessed individually as to their %ishes andoverall medical condition to determine if they are %ell enough to %or+"

9ther Resources for 1ore Information on Enteral and Parenteral

Nutrition

9ley 0oundation B The 9ley 0oundation is a national# independent# non-profit C;2 (c) (<) organiation that provides information and psycho-social support to consumers of home parenteral (IA) and enteral (tu$e-fed) nutrition (homePEN)# helping them live fuller# richer lives" The0oundation also serves as a resource for consumers families#homePEN clinicians and industry representatives# and other interestedparties" B%%%"oley"org

,5PEN B ,merican 5ociety for Parenteral and Enteral Nutrition B ,5PEN is a national organiation composed of nutrition professionalsincluding physicians# nurses# pharmacists# dietitians and mem$ers ofindustry %ho are dedicated to improve patient care $y advancing thescience and practice of clinical nutrition" B %%%"nutritioncare"org

&uthor's( and Publication )ate's(

Donald F. Kirby, MD, FACG, and Keely Parisian, MD, The ClevelandClinic, Cleveland, OH B Pu$lished 5eptem$er :;22"

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enteral and parenteral nutrition

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