T1 L13: Nutrition support

• What is the social importance of feeding?

  • A Basic requirement
  • Provides Nurture
  • Is Symbolic
  • Means “Caring”
  • Is a Social Binder
  • Confers psychological benefits
• How does the route of oral nutritional support go?

  Food first: Safest, Cheapest, Most acceptable

  If restricted to fluids or not eating enough: Oral nutrition, supplements

  UNLESS IT IS CONTRA-INDICATED: Unsafe swallow, damaged/non-functioning gut
• When is oral nutrition unsuccessful and what is done for it?

  unsafe swallow, unable to eat despite oral nutrition supplements

  then:

  1. ENTERAL: using gut

  unless contraindicated; damaged / leaking / short / atonic / obstructed gut, then:

  2. PARENTERAL: bypassing gut
• What is enteral nutrition?

  Nutritionally complete liquid feeds through various tubes which access the gut, eg:

  • Nasogastric tube
  • Gastrostomy tube
  • Jejunostomy tube
  • Nasojejunal tube
  • Nasoduodenal tube
• What is parenteral nutrition?

  Nutritionally complete liquid feed which is broken down – to glucose /amino acids / fats & engineered to be safely administered intravenously

  
  

  Use if gut NOT functioning

  eg:

  • PPN: Partial parenteral nutrition
  • TPN: total parenteral nutrition
• What are the reasons for using enteral nutrition?

  gut functioning, but:

  • Unable to swallow (Includes unconscious)
  • Insufficient oral intake despite supplements
  • Unable to tolerate supplements
  • Patient choice
• What are the reasons for using parenteral nutrition?

  gut NOT functioning, because:

  • Aperistaltic
  • Obstructed
  • Too short (most always when less than 100cm of small bowel remaining)
  • Too damaged
  • High fistula
  • Inaccessible
• How are the different types of enteral access named?

  • Route of access– Nasal vs. percutaneous
  • Where the feed is being delivered– Gastric vs. jejunal
  • How was the access put in– Endoscopic vs. interventional radiology
• What are the advantages of naso-gastric tube feeding?

  • Uses the gut → physiological
  • Fast and easy to pass tube
  • Can be done at the bedside by most nursing staff
  • Minimally invasive
  • Generally well tolerated
  • Easy to remove if not tolerated / no longer required
• Who is naso-gastric tube feeding suitable for?

  • Working gut
  • Stomach emptying (into duodenum)
  • Safe to put tube through nose and down oesophagus
  • Patient must accept / tolerate the tube
  • Short-term feeding (up to 8 weeks) e.g. whilst unconscious on ITU, post-op, post-stroke, acute illness
• What are the risks of naso-gastric feeding?

  • Tube misplaced / displaced /blocked
  • Reflux / aspiration
  • Not tolerated:
  • Tube itself or
  • volume of feed infused
• How do we confirm correct placement of naso-gastric tube?

  The chest x-ray – upper oesophagus down to below the diaphragm

  The NG tube should:

  • remain in the midline down to the level of the diaphragm
  •  bisect the carina(T4)
  • The tip should be clearly visible and below the diaphragm
  • The tip should be several cm (10) beyond the GOJ to be confident that it’s within the stomach

  
• What is the NG care bundle?

  • safety checklist for nasogastric feeding
  • Aimed at avoiding feeding through a misplaced tube
  • Lots of documentation required to assure adherence to care plan

  
• What is naso-gastric (NG) feeding?

  enteral feeding where tube goes from nose to stomach

  
• What is Naso-jejunal feeding?

  Enteral feeding where tube goes from nose to jejunum

  
• What are the advantages of naso-jejunal feeding?

  As for NG feeding plus:

  • Vomiting / gastroparesis / duodenal obstruction
  • Minimally invasive – although may need x-ray or endoscopy to place
  • Less likely to aspirate / get misplaced
• What are the risks of naso-jejunal feeding?

  • Technically difficult
  • Generally needs endoscopy or placement in interventional radiology
  • This can create delay in feeding
  • Risk of mis/displacement
  • May still not be tolerated
• What are PEG and RIG?

  Percutaneous endoscopic gastrostomy (PEG) or Radiologically Inserted Gastrostomy (RIG)

  feeding rube inserted straight into stomach

  
• What are the advantages of PEG and RIG?

  • Uses the gut /physiological
  • Durable
  • Tubes last up to a couple of years
  • Unlikely to be accidentally displaced
  • No tube in throat / onface
  • Comfort
  • Cosmetic

  
• Who is PEG / RIG suitable for?

  Patients with:

  • a functioning gut
  • Inability to swallow adequate food/fluid
  • Due to an irreversible or long-lasting cause
  • In whom nutrition support is thought to be appropriate
  • Who can tolerate an endoscopy and minor surgical procedure
• What are the risks and shortcomings of PEG / RIG?

  • Perforation
  • Sepsis (Peritonitis and skin infection)
  • Bleeding
  • Perforated viscous
  • Attached to a pump 20 hours per day
  • Misplacement
  • Reflux
  • Buried bumper
  • Death (6% at 30 days)
  • Not involved in mealtimes
  • Alteration in body image
• What are the possible complications of PEG / RIG?

  • Peritonitis due to misplacement of tube and leak of feed
  • Buried bumper (stomach grows around bumper)
  • granulation around bumper
• What is percutaneous jejunal access (PEJ)?

  also: Surgical jejunostomy / PEJ/ RIJ

  feeding tube directly into small bowel (jejunum)

  
• What are the advantages of PEJ?

  As for PEG plus:

  • Tolerated if gastroparesis/duodenal obstruction i.e. longterm option for those requiring NJfeeding
• What is gastroparesis?

  Condition concerning muscles of the stomach which results in delayed gastric emptying

  
• What are the risks of PEJ?

  • As for PEG but higher risk of complication due to position / anatomy of small bowel
  • Hence existence of PEG-J a PEG with an extension into the jejunum – best of both worlds
• What does total parenteral nutrition (TPN) consist of?

  • Fluid
  • Electrolytes
  • Protein – as amino acids
  • Fat
  • Carbohydrate
  • Vitamins
  • Minerals

  
• What are central access lines?

  Intravenous lines to insert TPN

  
• What are the problems with TPN?

  • Line “access” complications: Misplaced line, Extravasation (leakage) of TPN, Clot on the line (thromboembolism), Line infection
  • Hyperglycaemia
  • Fluid / Electrolyte disturbance
  • Over or under-feeding
  • Liver disease
  • Gut not being used → atrophy and inflammation
  • Expensive
• How is TPN monitored?

  4 hourly:

  • Observations including temperature
  • Blood glucose

  Daily:

  • U&E, Mg, Ca, phosphate, LFT, FBC
  • Line inspection
  • Weight

  Monthly:

  • Micronutrients
  • Triglycerides
• What is re-feeding syndrome?

  Refeeding syndrome is defined as:

  • severe electrolyte and fluid shifts
  • associated with metabolic abnormalities
  • in malnourished patients
  • undergoing refeeding

  whether orally, enterally or parenterally.
• What is the pathogenesis of re-feeding syndrome?

  starvation -> trans-membrane pumps switched off to save energy -> Na+ and water diffuse in, K+ and phos diffuse out of cell (total body depletion) -> re-feeding -> energy -> pumps switched back on immediately:

  • sudden drop of plasma K+ and phos -> arrhythmias
  • sudden surge in plasma Na+ and water -> overload
• What are the complications of re-feeding syndrome?

  Electrolyte imbalances, fluid shifts, and organ dysfunction

  hypocalcaemia, hypophosphotaemia, hyponutriaemia, generalised oedema, pulmonary oedema, heart failure, death

  
• How to avoid/treat re-feeding syndrome?

  • Be aware of the risk
  • Check electrolytes (Na, K, Mg, Ca,Phos)
  • Begin replacement before feeding
  • Rule of thumb: start slow and build up
  • As low as 5-10kcal/kg/24hrs
  • Keep monitoring electrolytes daily(!) and replacing as necessary
• What is Wernicke-Kosakoff's (WKS) Syndrome?

  Acute thiamine deficiency

  Precipitated by providing calories in the absence of sufficient reserves of thiamine– i.e. by re-feeding

  • Wernicke’s: opthalmoplegia, unsteady gait, nystagmus, confusion
  • Reversible – but only if you act very quickly to give IV thiamine
  • Korsakoff’s psychosis: sudden onset, dramatic, irreversible memory loss, confabulation

  
• How to avoid/ treat WKS?

  • Be aware of the risk
  • Replace thiamine before and during re-feeding
  • If low risk and able to eat, use high dose oral thiamine
  • If high-risk or not eating, then use IV Pabrinex

  
• What is the significance of 'basic care'?

  part of 'basic care': procedures essential to keep an individual comfortable

  Appropriate basic care should always be provided unless actively resisted by the patient
• What is the potential ethical dilemma surrounding PEG / NG feeding?

  For:

  • Feeding and hydration, however provided, is part of basic care & should not be withdrawn, Withdrawing them = starving someone to death

  Against:

  • requires medical / nursing skills
  • has side effects
  • is medical treatment
  • And therefore could be withdrawn if thought not to be providing benefit
• At what circumstances could artificial feeding be withdrawn / not done?

  If feeding requires medical intervention AND is not thought to be providing benefit

  A discussion of benefit vs. risk needs to be had with patient / family (NOK) involvement