3. nutrition support

1. Nutrition Support Noraishah Mohamed Nor Dept Nutrition Sc IIUM

2. Introduction

3. Conditions That Require Specialized Nutrition Support Enteral —Impaired ingestion —Inability to consume adequate nutrition orally —Impaired digestion, absorption, metabolism —Severe wasting or depressed growth Parenteral Gastrointestinal incompetency (diminished intestinal fx ) Hypermetabolic state with poor enteral tolerance or accessibility Supplement to EN

4. Conditions in EN Diminished food intake Preoperative malnutrition Coma Postoperative ileus Hypercatabolic states Polytrauma Burn Sepsis Severe disease condition

5. Diminished digestion and absorption Pyloric stenosis Pancreatic disease Biliary disease Malabsorbtion syndrome Short bowel syndrome Radiation enteritis Ulcerative colitis Duodenal fistula Chronic disease Chronic cardiac, hepatic, renal disease Malignant disease

6. Changes in metabolic rate and nitrogen excretion with various types of physiologic stress

7. Indications for Enteral Nutrition Inadequate amount nutrients and/or calories ingested will lead to malnutrition- associated with an increased incident of: Poor wound healing Impaired immune response and response to trauma Increased risk of sepsis Altered gut structure/function causing malabsorption and spread of bacteria

8. Ultimately malnutrition will lead to: Prolong recovery period Increased need for nursing care Increased risk of serious complications Prolong hospital stay Increased medical cost

9. Contraindications for EN Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted Inadequate resuscitation or hypotension; hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished

10. Advantages - Enteral vs PN Preserves gut integrity Possibly decreases bacterial translocation Preserves immunological function of gut Reduces costs Fewer infectious complications in critically ill patients Safer and more cost effective in many settings

11. Advantages - Enteral nutrition Intake easily/accurately monitored Provides nutrition when oral is not possible or adequate Supplies readily available Reduces risks associated with disease state

12. Disadvantages— Enteral Nutrition GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax Costs more than oral diets (not necessarily) Less “palatable/normal”: patient/family resistance Labor-intensive assessment, administration, tube patency and site care, monitoring

13. Disadvantages - PN Gut mucosal athropy Overfeeding Hyperglycemia Increased risk of infectious complications Increased mortality in critically ill pt

14. Aims of Nutritional support Preserve lean body mass (protein) Increase protein synthesis Improve immune and muscle function More rapid recovery Shorten hospital stay Reduction of morbidity

15. Roles of nutrition support dietitian Working with other health care professionals inc. pharmacist, nurse, clinician-to support, restore, maintain optimal nutritional health for individuals with potential or known alterations in nutritional status Assures optimal nutrition support though implementation of nutrition care process related to delivery of EN and PN support (Fuhrman et al 2001)

16. Nutrition care process Individual nutritional status assessment Indentify nutritional diagnosis Implement appropriate interventions Monitor & reassess an individual’s response to the nutrition care delivered Evaluate outcomes-incl. the need for transitional feeding care plan or termination of nutr . Support intervention (Lacey & Pritchett, 2003)

17. Algorithm to choose nutritional support Nutritional assessment of the patient Normally nourished Normally nourished but will develop malnutrition because of disease process if support withheld malnourished Normal feeding Nutritional support indicated

18. Different ways to provide nutrition support Oral Enteral Parenteral Combined

19. WHEN THE GUT WORKS – USE IT!

20. Signs of functioning GIT The present of bowl sound Soft, non-tender abdomen Passage of fistulas/stool Intact appetite

21. Enteral nutrition by mouth Common sense Adequate Palatable Varied Nutritional complete Provided at regular intervals, more frequentyly than regular meal times if necessary Progressively increasing in heaviness and complexity

22. Cleanliness In preparation and serving of food and utensils to prevent GIT infection Compassion Ensuring the patient ingests the preferred food Putting food in patient’s reach Conducive eating environment Involving dietitians in food selection and preparation

23. Enteral nutrition by tube Nutrition provided through the gastrointestinal tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity Benefits of EN: Help maintain gut mucosal physiology May modulate immune response-p revent translocation of bacteria and toxins (maintain gut mucosal integrity)- IgA in EN ( IgA prevent absorption of enteric antigents )-less risk for infection Promote peristalsis Safer: fewer complication Lower cost-formula, delivery system and less patient care Simpler system-care and self-administrator

24. Clinical setting in which enteral nutrition should be part of routine care PEM with inadequate oral intake of nutrients for the previous 5 days Oral intake <50 % of required needs for the previous 7-10 days Severe dsyphagia due to strokes, brain tumors , head injuries, multiple sclerosis Major (>30 % of BSA), full thickness burns Short gut due to small bowel resection- enteral nutrition + parenteral nutrition to stimulate regeneration of the remaining intestine

25. Clinical conditions in which enteral nutrition usually may be helpful: Major trauma with functional GIT + inadequate oral intake for 7-10 days Radiation therapy for cancers of the lungs, head, neck and cervix, and lymphomas Acute/chronic liver failure + severe anorexia + functioning GIT Severe renal dysfunction (<5% of normal glomerular filtration) + anorexia + functioning GIT

26. Contraindications for enteral feeding: Mechanical obstruction of GIT Prolong ileus Severe GI haemorrhage Severe diarrhoea Intractable vomiting High-output GIT fistula (>500 ml/day) Severe enterocolitis

27. Tube feeding routes

28. Transnasal passage Transnasal passage of feeding into the stomach/intestine employed when possible A surgical procedure can be avoided Generally well tolerated when small-bore feeding tube are used Disadvantages: tube can be readily removed by disorientated/uncooperative px . When larger, stiffer tube used-irritation to nasal passages, pharynx, esophagus & compromise gastroesophageal competency

29. Nasogastric insertion & placement of the tube is easier. Nasogastric , esophagostomy , gastrostomy feeding allow the digestive process to begin in the stomach-decreasing risk of dumping syndrome. Disadvantage: higher risk of aspiration-only gastroesophageal sphincter is operating to prevent reflux

30. Nasoduodenal , nasojejunal , jejunostomy : Advantage: Posed less risk of regurgitation-advantage of gastroesophageal sphinctar & pyloric sphincters Disadvantages: Higher risk of intolerance (nausea, vomiting, diarhea , cramps)-when feeding are not properly selected. The bactericidal effect of HCL in the stomach is bypassed-need attention for sanitation to formula and equipment

31. Ostomies Require surgical insertion. Indicated when insertion through transnasal is impossible or when long-term feeding is anticipated Advantages: irritation caused by the feeding tube is eliminated Ostomies are unobtrusive between feeding time

32. Jejunostomies : Advantage: permits early post operative feeding (unlike stomach & colon)-the small bowel is not affected by postoperative ileus . Relatively safe, comfortable, potential for long-term use Disadvantage: Possibility of infection is high like other ostomy procedure

33. EN administration Administration of EN should be guided by: Px’s age Underlying disease Enteral access device Condition of GI

34. When the patient should be started with EN? Eary initiation of EN is beneficial if px is hemodynamically stable In ICU, when EN was initiated within 24-48 hrs of admission: Lower rates of infection Shorter hospital stay (Bar et a. 2004)

35. Methods of delivery Based on: Nutrient needs Feeding site Formula selection Current medical status 3 methods of delivery: Bolus feeding Intermittent bolus feeding Continuous feeding

36. Bolus feeding: Administered using a syringe/feeding reservoir Infused over a period of time Tolerance is dependent on the functional ability of the gut Generally, the px is fed a vol of 250-400ml of formula-5-8x/day Allow px greater freedom/movement between feeding times Associated with high incidence of complications: Nausea Vomiting Diarrhoea Abdominal distension & cramps Aspiration

37. Intermittent bolus feeding: Administered by slow gravity drip Each feeding is given over 30 min every 3-4 hrs Tolerance is dependent in the functional ability of the gut Initiation of feeding with 50 ml of isotonic formula (<30ml/min) every 3-4 hrs Progression of feeding regime with additional 50 ml every 8-12 hrs as tolerated Generally, prescribed vol of formula 250-400 ml infused over a 20-30 min period 5-8x/day Allow px greater freedom/movement between feeding times. Complications can be similar to bolus feeding

38. Continuous feeding Utilised when bolus/intermittent feedings are not tolerate/in critical ill patients/small bowel feeding Usually pump assisted Associated with reduced incidence of high gastric residual, GER and aspiration Restricts px movement

39. Continuous tube feeding Initiation of tube feeding range from 20-50ml/hr Progression of tube feeding range from 10-20ml/hr every 8-24 hrs until the desired volume is attained the strength can be increased as tolerated. If feeding is not tolerated-reduce the rate & strength to previously tolerated level-gradually increase the rate & strength again Avoid altering rate & strength at the same time

40. Part 2--NUTRITION Support for critically ill

41. E nergy R equirement Haris Benedict Equation Male REE = 66.47+13.75W+5.0H-6.76A Female REE = 665.10+9.56W+1.85H-4.68A W= wt in kg H = ht in cm A = age in years Formula FAO/WHO/UNU (1985)   Male 18 – 30 REE = 15.32W+679 30 – 60 REE = 11.2W+879 >60 REE = 13.5W+987 Female 18 – 30 REE = 14.7W+496 30 – 60 REE = 8.7W+829 >60 REE = 10.5W+596

42. Ismail et al.(1998) Men 18 – 30 years:BMR =0.0550(W)+2.480 MJ/d 30 – 60 years:BMR =0.0432(W)+3.112 MJ/d   Women 18 – 30 years:BMR =0.0535(W)+1.994 MJ/d 30 – 60 years:BMR =0.0539(W)+2.147 MJ/d

43. Activity and stress factors Activity Factor =1.0 – 1.1 (bed rest) = 1.2 – 1.3 (very light) =1.4 – 1.5 (light) = 1.6 – 1.7 (moderate activity) =1.9 – 2.1 (highly active) = 2.2 – 2.4 (strenuous)

44. Stress Factor : =1.1(mild malnutrition, postoperate no complication =1.2(mild illness confined to bed) =1.3(mild illness ambulatory) =1.2-1.3 (surgery major) =1.3-1.4 (trauma skeletal) =1.2 – 1.3(mild infection and stress) =1.4 – 1.5(moderate infection and stress) =1.6 – 1.8(severe hypercatabolic ) =2.0 – 2.2(sepsis) =1.2 – 1.4(<20%BSA) =1.5 – 1.7(20 – 40%BSA) =1.8 – 2.0(>40%BSA) =1.2 – 1.3(Fracture) =1.4 – 1.5(respiratory or renal failure) =1.4 – 1.8(COPD) =1.5 – 1.6(Cancer with chemo or radiation,cardiac cachexis )

45. Types of enteral Products Standard/polymeric formulas Elemental Modular (Supplements) Condition Specific

46. Polymeric formula Composed of intact proteins, disaccharides,polysaccharides , variable amounts of fat and residue Require a functioning GIT for absorption and digestion Category Characteristic Indication Products Standard Nutritionally complete Provide 1 kcal/ml Distribution: 50-60 % CHO 10-15 % Protein 25-30 % fat Normal digestive & absorptive capacity Ensure/ Nutren Optimum/ Osmolite Fiber-suplemented Similar to standard formula except for fibre content 4 – 20g of dietary fibre /l Constipation, diarrhoea Jevity / Nutren Fibre / Nutren Diabetic

47. Category Characteristic Indication Products Concentrated Similar to standard formula except provide 1.5 – 2.0 kcal/ml Fluid restriction Ensure Plus, Enercal Plus

48. Elemental formula Partially hydrolyzed protein Characteristic Indication Products Nutritionally complete Usually provide 1 kcal/ml May contain glutamine Reduced digestive & absorption capacity e.g. Crohn’s Disease, Short Bowel Syndrome, long term fasting with gut atrophy, post operative patients Peptamen / AlitraQ , Elementum

49. Modular Formulas Single nutrient supplement, nutritionally incomplete, usually low in electrolytes Examples : Fat-MCT oil (Medium Chain Triglyceride) CHO- Carborie , Polycose (Glucose polymer) Protein- Myotein

50. Condition specific products Condition Characteristic Indications Product Metabolically stress Nutritionally complete Provides 1.5 kcal/ml High in protein: >20 % kcal May contain: arginine,nucleotides , omega-3 fatty acids Polytrauma /post operative period (following major surgeries) Perative Hepatic Encephalopathy Protein content: high in BCAA, low in Aromatic Amino Acids Hepatic Encephalopathy Falkamin Protein, electrolyte and fluid restriction Provides 2.0 kcal/ml Low in protein Low in phosphorous Acute or chronic kidney disease not on dialysis Suplena (NA) Glucose Intelorance Nutritionally complete Provides 1.0kcal/ml Low in CHO: 35 % of kcal High in fat: 40-50% of kcal Fibre supplemented Hyperglycaemia :> 10mmol/L Glucerna / Nutren Diabetik / Nutricomp ® Diabetic

51. Condition Characteristic Indications Product CO 2 retention Nutritionally complete Provides 1.5 kcal/ml High in fat: 55 % kcal & Low in CHO: 30% kcal Chronic obstructive pulmonary disease with CO 2 retention Pulmocare Electrolyte and Fluid restriction Provides 2.0 kcal/ml Moderate in protein Low in phosphorous Acute or chronic renal failure requiring dialysis Nepro / Nutricomp ® Renal

52. Immune-Enhancing Formulas Have added “immune-enhancing” nutrients ( arginine , glutamine, omega-3 fatty acids, nucleotides) Results of research have been mixed Multiplicity of active ingredients makes it difficult to control variables Meta-analysis suggests that they might be most beneficial in surgical patients Some evidence of harm in septic patients

53. Evidence- based Glutamine should be added to standard formula in: Burn & trauma patients In Burns pt, the trace elements (Cu, Zn, Se) should be supplemented in higher dose For the trauma patient, it is not recommended to routinely use immune-enhancing EN, as its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation. Diet supplemented with arginine should not be used for critically ill pts.

54. Formulas for impaired GI fx : Infant/Children Protein Hydrolysate Pregestimil Alimentum Peptide/ Elemental Neocate Peptamen Jr. Vivonex Pediatric Neocate advance

55. Initiation of feeding Choose full strength, isotonic formulas for initial feeding regimen. Initiation and advancement of enteral formula in pediatric patients is best done over several days in a hospital setting using a flexible nutrition plan.

56. Initiation of feeding- Paediatric Continuous feeding Generally children are started isotonic formula at a rate of 1-2 mL /kg/h for smaller children 1mL/kg/h for larger children over 35-40 kg. The rate is advanced based on tolerance by the child the goal of providing 25% of the total calorie needs on day 1. Bolus feeding 2.5-5 mL /kg can be given 5-8 times per day with gradual increases in this volume to decrease the number of feedings to closer to 5 times daily.

57. Initiation of feeding-children Bolus feedings & gravity-controlled feedings started with 25% of the goal volume divided into the desired number of daily feedings. Formula volume may be increased by 25% per day as tolerated, divided equally between feedings Pump-assisted feedings A full-strength, isotonic formula can be started at 1-2 mL /kg/h and advanced by 0.5-1 mL /kg/h every 6-24 hrs until the goal volume is achieved

58. For preterm, critically ill, or malnourished children Use pump initial volume : 0.5-1 mL /kg/hour Advancing to 10-20 ml/kg/day

59. Initiation of feeding-adults Bolus feedings & gravity-controlled feedings full-strength formula 3-8 times per day increases of 60-120 mL every 8-12 hours as tolerated up to the goal volume. Pump-assisted feedings initiated at full strength at 10-40 mL /h and advanced to the goal rate in increments of 10-20 mL /h every 8-12 hours as tolerated

60. Patient Positioning Elevate the backrest to a minimum of 30º-45º, for all patients receiving EN unless a medical contraindication exists. Eg.unstable supine, hemodynamic instability, prone position If necessary to lower the Head-to-bed (HOB) for a procedure or a medical contraindication, return the patient to HOB elevated position as soon as feasible.

61. Flushes-Practice Recommendations Flush feeding tubes with 30 mL of water every 4 hours during continuous feeding or before and after intermittent feedings in an adult patient flush the feeding tube with 30 mL of water after residual volume measurements in an adult patient Flushing of feeding tubes in neonatal and pediatric patients should be accomplished with the lowest volume necessary to clear the tube

62. MEDICATION ADMINISTRATION Do not add medication directly to an enteral feeding formula. Avoid mixing together medications intended for administration through an enteral feeding tube to reduce risks of: physical and chemical incompatibilities, tube obstruction altered therapeutic drug responses Dilute medication appropriately prior to administration.

63. Refeeding syndrome Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding . These complications are often worsened by overfeeding or by use of aggressive repletion.

64. Physiologic changes occur during refeeding Intracellular mineral depletion Hypophosphatemia hypomagnesemia , Hypokalemia body fluid disturbances (“ refeeding edema”) vitamin deficiencies ( eg , thiamine) lifethreatening cardiac arrythmias respiratory arrest Congestive heart failure

65. Consequences of electrolyte abnormalities

66. Patients at High Risk of Refeeding Patients with any of the following: BMI < 16 kg/m 2 Unintentional weight loss >15% within the last 3-6 months Very little or no nutrition for >10 days Low levels of potassium, magnesium or phosphate prior to feeding

67. Patients with 2 or more of the following: BMI < 18.5 kg/m 2 Unintentional weight loss >10% within the last 3-6 months Very little or no nutrition for >5 days A history or alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics

68. Monitoring For Refeeding Syndrome Monitoring metabolic parameters prior to the initiation of EN feedings and periodically during EN therapy should be based on protocols Prevention of refeeding syndrome is of utmost importance Px at high risk for refeeding syndrome and other metabolic complications should be followed closely, and depleted minerals and electrolytes should be replaced prior to initiating feedings.

69. Patients at risk of developing refeeding syndrome should be identified, electrolyte abnormalities should be corrected prior to the initiation of nutrition support. Nutrition support should be initiated at approximately 25% of the estimated goal and advanced over 3-5 days to the goal rate. Serum electrolytes and vital signs should be monitored carefully after nutrition support is started

70. Challenges in Nutritional Support Caloric requirement not met Under ordering by physician Reduced delivery Slow advancements Gut dysfunction High residual volume (GRV) Nausea Vommiting Absent of bowel sound Diarrhea Aspiration

71. Procedure and diagnostic test  require fasting Lack of enthusiasm, personal bias and individual practice

72. The risk factors for aspiration Sedation supine patient positioning the presence and size of a nasogastric tube malposition of the feeding tube mechanical ventilation, vomiting bolus feeding delivery methods poor oral health nursing staffing level advanced patient age

73. Strategies to optimized Delivery & Minimized Risk Use feeding protocol Motility agent ( eg . Prokinetic ) Small bowel vs gastric feeding Body position Nutrition support practice

74. Feeding Protocol e.g. Prospective evaluation before and after evidence based protocol introduction of EN in surgical pt.. Within 24 – 48 hr With the protocol: Inceased delivery of nutirents Shortened duration of mechanical ventilation Decrease mortality

75. Prokinetic agent: metoclopramide IV administration of metoclopramide or erythromycin should be consider in pt with intolerance to EF E.g with high gastric volume

76. Levels of GRV Severity Definition Treatment Mild <200 ml Return GRV Continue feeding Moderate 200 – 500 ml 1 st episode continue 2 nd episode start prokinetic agent 3 rd episode reduce EN by half 4 th episode: Stop feeding Place NJ tube Start EN protocol again Severe > 500 ml Stop gastric feeding Place NJ tube Start EN protocol Refer MNT pg 10 other assessment of tolerance

77. Small bowel feeding Small bowel fed pt have improved energy delivery in some studies Duodenal vs gastric feeding in ventilated blunt trauma pt Improved tolerance of EN and consequent faster achievement of desired calories Kortbreek JB J Trauma

78. Small bowel vs gastric feeding Maybe associated with a reduction in pneumonia in critically ill pt No different in mortality or ventilation days Small bowel feeding improves cal & prot intake and is associated with less time taken to reach target rate of enteral nutrition.

79. Nutrition Support Practices How should pt be tube fed after surgery? TF should be initiated within 24 hr after surgery Sholud satrt with low flow rate ( e.g 10 -20 (max) ml/hr)due to limited intestinal tolerance May take 5 – 7 days to reach the target intake Not consider harmful ESPEN guideline 2006

80. Nutrition Support Practices DO NOT…………..: Assemble feeding system on the pt’s bed Top up fresh formula until the formula hanging in the feeding bag has finished Overfed patients: High calorie density formula 1.3 kcal/ml  Perative 1.5 kcal/ml  Pulmocare 2.0 kcal/ml  nepro / enercal plus

81. Open vs Closed System Open System: Product is decanted into a feeding bag Allows modulars such as protein and fiber to be added to feeding formulas Less waste in unstable patients (maybe) Shortens hang time Increases nursing time Increased risk of contamination

82. Closed System or Ready to Hang: Containers sterile until spiked for hanging Can be used for continuous or bolus delivery No flexibility in formula additives Less nursing time Increases safe hang time Less risk of contamination More expensive than canned formula

83. Open System Hang time 8 hours for decanted formula; 4 hours for formula mixtures Feeding bag and tubing should be rinsed each time formula replenished Contaminated feedings are associated with pt morbidity Closed System Hang time 24-48 hours based on mfr recommendations Y port can be used to deliver additional fluid and modulars May result in less formula waste as open system formula should be discarded p 8 hours

84. Conclusion Practice early enteral feeding Use strict protocols Modify preoperative preparation Identify & rectify tube displacement Consider tube placement post pyloric Alter method of feeding (routine cycling, smaller volume , concentrated feeds ) Works as Nutrition Support Team Continuous Nutrition Education

85. Thank you…. Q???

86. Tutorial Male, age 39, 189 cm tall. 91 kg body weight, confined to bed and having burn of 40% TBSA and body temp is 39°. Calculate calorie req and plan a EN regimen . Female, age 41, 160 cm tall. 67 kg body wt. confined to bed and ventilated. Diagnosed with COPD. Calculate cal req and plan for EN regimen through pump feeding Pt with TPN, Patient on Nutriflex (peripheral) for three days after operation (75 ml/hr) Calculate the calorie from the TPN How to manage the pt if dr plan to change to EN