Download parenteral

Nutrition Support
Delivery of formulated enteral or
parenteral nutrients to maintain or restore
nutritional status
Two types:
enteral – delivery of nutrients into GI tract
through a tube
parenteral – delivery of nutrients into
blood steam intravenously
Why enteral support is thought to be
better (than parenteral)
By putting the nutrients into the gut, the gut
mucosa keeps toxic substances from getting into
the bloodstream & causing sepsis
1.GALT (gut associated lymphoid tissue) is part of
immune system – provides 70% of body
antibodies & contains lymphocytes
2. Maintain healthy bacteria in gut
3. Can give probiotics (lactobacillus)
4. Can give prebiotics (fiber &
fructooliogosaccharides FOSs)
Enteral Feeding:
indications for use
impaired food ingestion: dysphagia,
unconscious, fractured mandible,
respiratory failure, inability to suck
(premature infants)
impaired digestion of whole (intact)
foods: chronic pancreatitis, Crohn’s
disease, short bowel syndrome
cannot meet nutritional requirements:
major burn, trauma, anorexia nervosa,
severe wasting
When the gut works, use
it! safer - less risk of infection
 less expensive
 more easily done at home
than parenteral
Understand figure 23-1
Routes (access sites) for tube
feeding depend:
How long will feeding be needed?
Risk for aspiration of feeding into lungs
Surgical risk or no risk
Sites:
1. Nasal gastric (NG) Nasalduodenal or
Nasojejunal
2.PostpyloricGastrostomy-most common is PEG
Jejunostomy- PEJ
Tubes in nasal cavity
NG - nasogastric: short-term 3-4
wks, pt has low-risk of aspiration
(intact gag), normal digestion
NJ – nasojejunal (postpyloric):
short-term, pt with high risk of
aspiration, gastric or duodenal
surgery or disease
X Ray to verify placement of a tube
Gastrostomy (G Tube): for
long-term feedings
Need functioning stomach & intestines
more comfortable, for long term use > 4
weeks
PEG (Percutaneous endoscopic
Gastrostomy) a procedure using
endoscope to put special tube down into
stomach & out abdominal wall
other “G” tubes surgically placed
may use jejunum – jejunostomy, PEJ
Reasons not to use Enteral
Support
ileus - no bowel sounds
small bowel obstruction - SBO
severe diarrhea or vomiting
refusal of nutrition support by
patient or through Advance Directive
high-output fistula (>500 cc/day)
acute pancreatitis
can eat adequate amount by mouth
Choices for Enteral Formula
3 major types
Is GI tract functioning normally?
 YES = intact or polymeric formula
 NO = hydrolyzed formula
(monomeric)with polypeptides or
amino acids & some MCT oil
when disease specific formulas
warrented: renal, diabetes, hepatic,
pulmonary, severe stress & trauma
Immune Boosting Properties
in Enteral Feedings
Impact, Perative, Crucial (p 1233)
Glutamine: primary energy source for
rapidly ÷ cells; increases T cell production
Arginine: increases T cells
Omega-3-fatty acids: causes less
inflammation in cells, increases N balance
Nucleotides: used to form DNA
Enteral Formula Selection:
other factors to consider
Age - special formulas for pediatrics
Caloric density 1 kcal/cc to 2 kcal/cc
Protein density of formula (g/liter)
Na, K, Mg, P content?
Would fiber be beneficial?
CHO sources in formulas: hydrolyzed
corn starch, maltodextrin, soy fiber,
corn syrup solids - all lactose-free
Enteral Formula Selection
Osmolality (size and number of
nutrient particles in a solution). If
high (600 - 900 mOsmol/kg) fluid
drawn into gut  diarrhea
Example: Osmolite = 1.06 kcal/cc,
14% pro, 57% CHO, 29% fat, Cal:N
178, Osmol 300, 1887 cc to get RDA,
80% free water, casein & soy pro,
maltodextrin, safflower, canola, MCT
Tube Feedings
at home, person with healthy immune
system, could use home made blenderized
tube feeding
water is used to “flush” or clean the tube this water is part of individual’s fluid
requirement & given during the day
How are tube feedings given?
1. Continuous drip using a pump
2. Intermittent drip using a pump
if person eats some food during the day
tube feeding may be given at night
3. Bolus using gravity instead of pump;
given as a bolus 4-6 bolus times/day
How is a patient on tube
feeding monitored?
gastric residuals (checked by RN)
stool frequency and consistency
urine output adequate (I and 0)
 change in wt  ↓
Na, K, BUN, creatinine, glucose
albumin or prealbumin, Ca, P, Mg
seen/charted by RD every 3-7 days
Complications
of Tube Feeding
diarrhea
high gastric residuals
constipation
aspiration pneumonia – tube feeding
into lungs
pt pulls out tube
Complications
in patient on tube feeding
hyperkalcemia
azotemia (BUN,  Cr due to ECF)
prerenal azotemia: BUN > Cr 10:1
hyponatremia
hyperglycemia
hypoglycemia
How much tube feeding does
one give?
1.
2.
3.
Determine the number of kcal pt needs during
nutrition assessment
Decide site for access & type of tube feeding needed
Kcal needed day kcal ÷ ml of feeding = cc needed/ 24
hrs
Example:
1. use NG tube, Nutren 1.0 with fiber
2. pt needs 1629 kcal/day÷ 1.0 kcal/cc
3. 1629 ÷ 24 (hr) = 68 cc/hr continuous drip
Parenteral Nutrition indications for use
GI tract is not functioning well enough to
meet nutritional needs of patient so
nutrients put in bloodstream intravenously
examples:
small bowel resection
small bowel obstruction
large output fistula below enteral feeding
site
Parenteral Nutrition – access sites
(where it can go into the bloodstream)
Central access: requires surgical
placement of catheter in large, high blood
flow vein (total parenteral solution TPN)
PICC line: “tunneled” catheter inserted in
vein in arm; solution taken to high blood
flow vein (TPN)
Peripheral access: catheter tip placed in
vein in arm. Requires a more dilute
peripheral parenteral solution. (PPN)
Solutions: CHO = D15
Supplied as dextrose: 10% to 35%
10%= 100 gm/L, 25% = 250 gm/L
dextrose = 3.4 Kcal/gm
1 liter of 10% soln=(100gm x
3.4Kcal/gm = 340 Kcal)
PPN- Peripheral Parenteral Nutrition
is put into small (peripheral) vein so
cannot use more than D1o
Solutions: Protein
= D15 with 2.5% aa @ 60cc/hr
supplied as aa both essential &
nonessential: choices:
2.5, 4.25, 5% solutions (2.5% = 25 gm/L
4.25% soln = 42.5 gm/L)
protein =4 Kcal/gm; often not be included in
total Kcal
60 cc x 24 = 1.44 L x 25 g/L = 36 gms in
24 hrs & 144 kcal of prot
1.44 L x 150 gm/L = 216 g dextrose x 3.4
kcal/gm = 734 kcal in 24 hrs
Parenteral Nutrition
Solutions: Lipids
Supplied as aqueous suspension of
soybean or safflower oil with egg yolk
phospholipids as the emulsifier. Glycerol is
added to suspension.
2 levels of emulsions:
10% solution: 1.1 kcal/mL
20% solution: 2.0 kcal/mL
D15 with 2.5% aa @ 60cc/hr and
10% IL at 11 cc/hr
11 cc/hr x 24 hr = 264 cc x 1.0 kcal/cc =
264 kcal/day
Total kcal: 1142
Kcal from fat: 264 (23%)
Kcal from CHO: 734 (64%)
Kcal from prot: 144 (13%)
Parenteral Nutrition Solutions
Guidelines for amounts of each to provide:
Protein: 15 - 20% of kcal
Lipids: ~30% of kcal
CHO: 50-65% of kcal
Electrolytes, vitamins, trace elements: lower
than DRI
Fluid: 1.5 - 2.5 liters total
Kcal: N ration: 125 kcal:1 gm N
Parenteral Nutrition Solutions
Prepared aseptically & delivered 2 ways:
“3 in 1” solution: pro,fat,CHO in one bag and 1
pump is used to infuse solution
2 bag method: pro & CHO in 1 bag & lipid soln
in glass bottle; each is hooked up to pump;
solutions enter vein together
Given continuously or cyclic (8-12 hrs/day)
Insulin may be added to solution
Parenteral Nutrition Solutions:
Selected Complications
Mechanical: thrombophlebitis
Infection and sepsis of catheter site
Gastrointestinal: villous atrophy
Metabolic: hyperlipidemia, trace mineral
deficiencies, electrolyte imbalance,
refeeding syndrome
Refeeding syndrome
Transitional Feeding
A process of moving from one type of
feeding to another with multiple feeding
methods used simultaneously
Examples:
parenteral feeding to enteral feeding
parenteral feeding to oral feeding
enteral feeding to oral feeding
Transitional Feeding
parenteral to enteral
1. Introduce enteral feeding – 30 cc/hr
while giving parenteral
2. If tolerated, gradually ↓ parenteral while
increasing enteral
3. Once pt can tolerate 75% of needs
enterally, d/c parenteral
Process is called a stepwise decrease
Transitional Feeding
parenteral to oral and enteral to oral
Use step-wise decrease method; wait until pt
accepting 75% oral and then decrease
parenteral or enteral method
But may need to:
Offer oral during the day & cycle other from 6pm 6am in order to ↑ provide motivation &
reestablish hunger patterns
Some children & adults may continue on oral
during the day and enteral at night
Nutrition Support
 most effective when provided as a team:
RD, RN, Pharm D in conjunction with MD
Various substances being investigated for
therapeutic effects
$$ so look for articles on cost-benefit
Know patient wishes for use – living will
and if there is an advance directive