residents presentation

7/30/2019 Residents Presentation

1/31

Objectives

Review ASPEN guidelines and gradingsystem

Review various modes of nutrition

support

Clinical indications/contraindications

Benefits of Enteral Nutrition

Parenteral Nutrition appropriateness


2/31

The American Society for Parenteral and

Enteral Nutrition (A.S.P.E.N) is dedicated to

improving patient care by advancing the science

and practice of nutrition support therapy

More than 5,500 members from around the world

consisting of dietitians, nurses, physicians, students,

pharmacists, and other health professionals

A.S.P.E.N Recommendations Task Force examines theavailable literature related to the ordering,

preparation, delivery, and monitoring of

enteral/parenteral nutrition and establishes

evidence-based practice guidelines.

A.S.P.E.N


3/31

The evidence supporting each recommendation is classified as

follows:

A: Guidelines supported by at least two level I investigations (large,

randomized trials)

B: Fair research-based evidence to support the guideline (supported by one

level I investigation)

C: Guideline is based on expert opinion and editorial consensus (supported by

level II investigations only- small, randomized trials)

D: Guideline is supported by at least two level III investigations (non-randomized, contemporaneous controls)

E: Guideline supported by level IV or level V evidence (non randomized,

historical controls, case series, uncontrolled studies, expert opinion)


4/31

Enteral Nutrition (tube feeding)

Short Term (


5/31

1. Access to an adequately functioning

gastrointestinal tract

2. Insufficient oral intake or impaired nutrient

digestion, absorption, or metabolism

Neurological disorders (ex. CVA with

dysphagia)

Severe gastroparesis

Hyperemesis gravidarum

Short bowel syndrome with >200 cm bowelremaining

3. Need is expected for >5-7 days for

malnourished patients or 7-9 days for

adequately nourished

Clinical Indications


6/31

Clinical Contraindications

1. Nonoperative mechanical GI obstruction

2. Intractable vomiting/diarrhea refractory to medical management

1. Severe short-bowel syndrome (less then 200 cm remaining)

2. Paralytic ileus

3. high-output enterocutaneous fistula

4. Severe GI bleed or severe GI malabsorption

5. Inability to gain access

6. Aggressive intervention not warranted


7/31

ASPEN Guidelines: Critical Care Nutrition support therapy in the form of enteral nutrition (EN) is the preferred

route of feeding over parenteral nutrition (PN) for the critically ill patient who

requires nutrition support therapy (Grade B)

Enteral feeding should be started early within the first 24-48 hours followingadmission (Grade C). The feedings should be advanced towards goal over thenext 48-72 hours

In the setting of hemodynamic compromise, EN should be withheld until thepatient is fully resuscitated and/or stable (Grade E)

In the ICU patient population, neither the presence nor absence of bowelsounds nor evidence of passage of flatus and stool is required for the initiation

of enteral feeding (Grade B)

Either gastric or small bowel feeding is acceptable in the ICU setting. Criticallyill patients should be fed via an enteral access tube placed in the small bowel ifat high risk for aspiration or after showing intolerance of gastric feeding(Grade C).


8/31

Complications/Risks of EN

Nasopharyngeal irritation and pain

Tube migration or dislodgement

GI obstruction from dislodged componentsof tube

Tube occulusion

Leakage, irritation or infection around thefeeding site

Peritonitis

Fistulas

Aspiration pneumonia


9/31

Benefits of Enteral Nutrition

EN preserves gut integrity

EN supports the structural integrityof the IgA producing immunocyteswhich comprise the GALT and inturn contributes to MALT at distant

sites- lungs, liver, and kidneys

Loss of functional gut integrityleads to increased permeabilityand increased risk of infection andMODS

Research shows less infectiousmorbidity, fewer infectiouscomplications, and significant costsavings compared to PN


10/31

Parenteral Nutrition

TPN

PPN

PICC


11/31

1. Documented inability to absorb adequate nutrients via the

GI tract such as:

Massive small-bowel resection (500 mL)

Clinical Indications


12/31

Functioning gastrointestinal tract

Treatment anticipated for less than 5

days in patients without severemalnutrition

Inability to obtain venous access

A prognosis that does not warrant

aggressive nutrition support

When the risks of PN are judged to

exceed the potential benefits

Contraindications for Parenteral

Nutrition


13/31

Central Line vs. Peripheral

PPN contains a lower concentrationof nutrients compared to Central PN

The osmolarity of PPN must notexceed 900 mOsm/L

PPN is not appropriate for patientson a fluid restriction. Adults requirelarge fluid volumes to deliveradequate nutrition support.

PPN is only indicated for short term

use

It can prevent malnutrition but it willnot correct existing nutritionaldeficits


14/31

ASPEN Guidelines: Critical Care If early EN is not feasible or available over the first 7 days following admission to the

ICU, no nutrition support therapy should be provided (Grade C). In the patient who

was previously healthy prior to critical illness with no evidence of protein-calorie

malnutrition, use of PN should be reserved and initiated only after the first 7 days of

hospitalization (when EN is not available) (Grade E).

If there is evidence of protein-calorie malnutrition on admission and EN is not

feasible, it is appropriate to initiate PN as soon as possible following admission andadequate resuscitation (Grade C).

If a patient is expected to undergo major upper GI surgery and EN is not feasible, PN

should be provided under very specific conditions:

- If the patient is malnourished, PN should be initiated 5-7 days pre-operatively and

continued into the post-operative period (Grade B)

- PN should not be initiated in the immediate post-operative period, should be

delayed for 5-7 days (should EN continue not to be feasible)

- PN therapy provided for a duration of less than 5-7 days would be expected to have

no outcome effect and may result in increased risk to the patient (Grade B)


15/31

Complications/Risks of PN

Central line associated bloodstream infections

Thrombosis

PN associated liver disease

Pneumonia

Fungemia

Sepsis

Pneumothorax

Volume overload

Acid base imbalance

Metabolic Bone Disease (long term use)


16/31

Nutrition Support: Collaboration

Nutrition support teams

have been shown to

improve patient outcomes

Increasing collaborationthrough nutrition support

teams decreases the use of

inappropriate parenteral

nutrition therapy

Inappropriate=not in

accordance with A.S.P.E.N.

Inappropriate PN costs $!


17/31

The Intervention

Policy initiated to require

pharmacy to inform RDs

about new PN patients

Intern presented

educational presentation at

nutrition support

committee meeting about

the importance of ASPEN

guidelines and

interdisciplinary

collaboration


18/31

The Study

Retrospective chart review examiningeach PN patient post intervention and

determining if PN was appropriate

and if RD was consulted

Does the intervention succeed inincreasing interdisciplinary

collaboration between physicians,

dietitians, and surgeons?

Does it succeed in increasing theappropriate percentage of PN?

Is interdisciplinary collaboration

(nutrition consults) related to the

appropriate use of PN?


19/31

Pre-Intervention

Month % of

Appropriate PN

% of

Inappropriate

%

Receiving

Nutrition

Consults

% of Cases

not

Receiving

Nutrition

Consults

Total # of

Cases

November2012

73% 27% 53% 47% 15

December

2012

44% 56% 44% 56% 9

January

2013

72% 28% 56% 44% 18

Mean 63% 37% 51% 49% 14


20/31

Post-Intervention

Month % of

Appropriate PN

% of

Inappropriate

%

Receiving

Nutrition

Consults

% of Cases

not

Receiving

Nutrition

Consults

Total # of

Cases

February

2013

61% 39% 50% 50% 18

March

2013

62% 38% 62% 38% 13

Mean 62% 39% 56% 44% 16


21/31

Statistical Analysis: Pearson Chi-Square

PN and Nutrition Consults November 2012-

March 2013X^2=8.47 df=1

P


22/31


23/31

Answer

A high output fistula is an indicator for PN. TPN reduces GI secretions therebynot exacerbating the output

EN is possible for non high output fistulas. If the fistula is in a proximallocation, pts can be fed enterally distal to the fistula using a PEG/J or an NJtube. If the fistula is very distal- such as distal ileal or colonic, the patient can

potentially obtain full nutrition by mouth or via gastric tube. If the fistula islocated in the small bowel too distal for a PEG/J to pass, yet not distal enoughto allow adequate enteral absorption proximal to the fistula, then thepossibility of fistuloclysis can be considered.

Fistuloclysis= placing a feeding tube directly into the fistula (there must be

enough unobstructed bowel distal to the fistula in continuity for adquatenutrient absorption.

Willcutts, K. The Art of Fistuloclysis: Nutritional Management of Enterocutaneous Fistulas. Practical Gastroenterology.September 2010.http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdf
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdfhttp://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/WillcuttsArticle.pdf


24/31

Case Study

82 YOF with PMHx significant for DM, PVD gastroparesis, aspiration PNA,

frequent falls, and advanced vascular dementia is admitted from NH after

being found aspirating on her lunch. SLP saw pt, recommended NPO with

alternative form of nutrition.


25/31

Answer

Nutrition support in patients with advanced dementia has not been shown topromote the healing of pressure ulcers, reduce the risk of aspiration PNA,increase patient comfort, functional status, or prolong survival whencompared to hand-feeding.

In 1999 Finucane and colleagues noted in a review of the literature that

enteral nutrition did not improve clinical outcome in advanced dementia, in2008 a Cochrane review concluded that there was insufficient evidence tosuggest that enteral nutrition benefits patients with advanced dementia. Bothstudies concluded that there is little efficacy for enteral nutrition in thispopulation.

Many families and clinicians misunderstand or overestimate the benefits ofnutrition support in advanced dementia. This can lead to ethical dilemmas.Evidenced based education and counseling can constructively address thesedilemmas.

Barrocas A, Geppert C, Durfee SM, et al. ASPEN Ethics Position Paper. December 2010. https://www.nutritioncare.org/Index.aspx?id=5850
https://www.nutritioncare.org/Index.aspx?id=5850https://www.nutritioncare.org/Index.aspx?id=5850


26/31

Case Study

67 YOM with Stage III supraglottic laryngeal cancer T3-N1-M0 s/p neck

dissection and total laryngectomy. Plan to begin XRT in 3 weeks . PMHx

significant for etoh abuse and tobacco use.


27/31

Answer

Use enteral nutrition to increase calorie and protein intake for outpatients

with stage III or IV head and neck cancer undergoing intensive radiation

treatment. Maintenance of nutritional status by EN during radiation

therapy may improve tolerance to therapy to promote better outcomes.

AND Evidence Analysis Library; Rating: Strong. http://andevidencelibrary.com/template.cfm?key=1754&auth=1

Based on 2 positive quality RCTs
http://andevidencelibrary.com/template.cfm?key=1754&auth=1http://andevidencelibrary.com/template.cfm?key=1754&auth=1


28/31

Case Study

59 YOF with a pmhx etoh abuse, p/w nausea, vomiting, and abdominal

pain radiating to her back. Pts admitting diagnosis is severe pancreatitis.

Today is hospital day #8, NPO day 9. Pt transitioned to CLD yesterday but

did not tolerate.


29/31

Answer

Patients with mild to moderate acute pancreatitis do not require nutrition

support therapy (unless an unexpected complication develops or there is

failure to advance to oral diet within 7 days (Grade C)

Patients with severe acute pancreatitis may be fed enterally by the gastricor jejunal route (Grade C)

Martindale et al. Crit Care Med 2009 Vol. 37, No. 5


30/31

Case Study

27 YOF G1P0 at 10 weeks gestation, p/w nausea and vomiting x 4 weeks.

PMHx significant for DM. Height: 55 Pre pregnancy Weight: 180#. Pt

unable to tolerate PO intake for 4 weeks, current weight: 170#


31/31

Answer

If a woman with HEG has not responded to dietary modifications,hydration, and oral antiemetics, EN should be initiated via NGT or NJT.

So far, gastric EN appears to offer more rapid relief of nausea and emesiscompared to small bowel feedings. Studies have found that EN has offeredsignificant relief from n/v and has led to positive fetal outcomes.

The use of PN in these patients should be avoided if possible. Pregnancysuppresses the immune system putting them at even greater risk forcentral venous catheter related bacterial and fungal sepsis. Pregnantwomen also have elevated coagulation factors making them more proneto catheter related thromboembolism. Cost of solution, compounding,and infusion supplies for PN is estimated at $1400 per week. Theestimated cost for home EN is $56 per week.

Lord LM, Pelletier K. Management of Hyperemesis Gravidarum with Enteral Nutrition. Nutrition Issues in Gastroenterology, Series #63.Practical Gastroenterology. June 2008

residents presentation

Documents