Basics of enteral and parenteral nutrition Surgical Nutrition

Basics of enteral and parenteral nutrition Surgical Nutrition Training Module Level 1 Philippine Society of General Surgeons Committee on Surgical Training

Objectives • To discuss the different feeding pathways for the surgical patients • To define and discuss key points of enteral and parenteral nutrition • To discuss the monitoring process and expected outcomes for surgical patients

Feeding Pathways Can the GIT be used? “Inability to use the GIT” Yes Tube feed No Oral “inadequate intake” Parenteral nutrition < 75% intake Short term Long term Peripheral PN Central PN More than 3 -4 weeks Yes No NGT Gastrostomy Nasoduodenal or nasojejunal Jejunostomy A. S. P. E. N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9 SA-12 SA.

EARLY ENTERAL NUTRITION

Early enteral nutrition: definition • Enteral nutrition that is initiated within 24 – 48 hours following hospitalization, trauma, or injury Zaloga GP. Crit Care Med 1999; 27: 259

Why early enteral nutrition? • The normal and designed route for nutrient intake, digestion, and absorption • Immunocompetence is a major function of the gastrointestinal tract • Non-utilization of the gastrointestinal tract even on a short term basis leads to complications in critical care or geriatric patient management • Cost-effective

Early enteral feeding: goal • To maintain intestinal mucosal integrity – Normal microvilli § Height and number – Normal intestinal barrier – Intestinal mucosal immunity

Early enteral feeding: rationale • Provide nutrients required during metabolic stress • Maintain GI integrity • Reduce morbidity compared with parenteral nutrition • Reduce cost compared with parenteral nutrition

Early enteral nutrition vs standard nutritional support on mortality Comparison: mortality Outcome: early enteral nutrition vs. control Study Treatment n/N Heyland et al. JAMA, 2001 Control n/N Cerra et al 1990 1/11 1/9 Gottschlich et al, 1990 2/17 1/14 0/19 1/51 24/163 1/16 0/18 2/47 12/143 1/17 Ross Products, 1996 Engel et al, 1997 20/87 7/18 8/83 5/18 Mendez et al, 1997 1/22 1/21 Rodrigo et al, 1997 2/16 96/197 2/13 4/13 86/193 17/89 28/87 Brown et al, 1994 Moore et al, 1994 Bower et al, 1996 Kudsk et al, 1996 Weimann et al, 1998 Atkinson et al, 1998 Galban et al, 2000 Pooled Risk Ratio 0. 01 0. 1 Higher for control 1 10 100 Higher for treatment

ENTERAL NUTRITION

Enteral nutrition access STOMACH JEJUNUM Nasogastric tube Nasojejunal tube PEG PEJ BUTTON JET-PEG PLJ Witzel, Stamm, Janeway NCJ PSG PFJ PFG E: Endoscopic G: Gastrostomy J: Jejunostomy L: Laparoscopic NC: Needle Catheter S: Sonographic F: Fluoroscopic Loser C et al. ESPEN guidelines on artificial enteral nutrition – Percutaneous endoscopic gastrostomy (PEG)

Access and delivery Nasogastric tube Nasoentericor jejunal tube PEG tube

Gastrostomy PEG placement, St Luke’s Medical Center

Post-pyloric feeding Short Term Long Term (operative) Nasoenteric – Nasoduodenal – Nasojejunal Jejunostomy – Percutaneous endoscopic jejunostomy or through the PEG tube – Surgical jejunostomy Gauderer MW, et al. J Pediatr Surg 1980; 15: 872 -875

Enteral Formulas – what type? • Polymeric formulas (80 -90%) • • • Commercial (preferred) Blenderized (If not critically ill, not severely malnourished) Oligomeric formulas Disease-specific formulas Modular formulas (concentrated protein and carbohydrate preparations)

Enteral nutrition delivery Gravity Feeding Enteral Pump Delivered

Practical points: enteral nutrition • If intake is within the range of 60% to 70% start oral supplement – Choose the product or preparation that meets all the daily requirements • If oral intake is 50% or less – You may give parenteral nutrition to supplement (good for a week – expensive, but more comfortable for the patient) – Cost-effective: NGT • If tube feeding duration will exceed 2 weeks and you are looking at long term (stroke or critical care) – gastrostomy is easier to maintain with lesser complications (aspiration)

Practical points: enteral nutrition • If patient will undergo surgery and you doubt patient will be able to have adequate intake for longer term: – Place gastrostomy during the surgery • If gastric function return is in doubt for more than a week: • Gastrostomy with jejunostomy tube extension • Surgical Jejunostomy • Main goal: adequate intake

Enteral formula: commercial vs. blenderized Commercial Formulas Blenderized Formulas Uniform contents Sterile Daily nutrient variability Non-sterile; high bacterial content and other pathogens High viscosity Does not provide adequate caloric density Low viscosity Lactose free Defined caloric density Gallagher-Alfred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001; 6: 43 -50 Sullivan MM, et al. J Hosp Infect 2001; 49: 268 -273

Bacterial contamination in standard tube feeds

Standard Feed: measured vs. expected 152 160 Calories (kcal/100 g) 140 129 120 106. 5 88 86. 9 80. 9 90. 2 expected 80 measured 53. 6 60 40 6 20 0 Hosp A Hosp B Commercial formula Hosp C Natural food formula 5. 5 Protein (gm/100 g) 5 Hosp D 3. 63 4 3. 1 3 3 2. 8 expected 2. 13 measured 1. 9 2 1 0 Hosp A Hosp B Commercial formula Hosp C Hosp D Natural food formula Sullivan MM et al. Nutritional analysis of blenderized diets in the Philippines (PENSA 1998)

Monitoring Gastric Residuals • • Monitor according to hospital protocol (e. g. , every 3 -4 hours) Volume not to exceed 50% of the amount infused Mentec H, et al. Crit Care Med 2001; 29: 1955 -1961

PARENTERAL NUTRITION

Parenteral nutrition: Indications • To avoid periods of starvation within 24 to 72 hours when oral or enteral intake are insufficient to achieve adequate intake in moderate to severe malnourished patients • When unable to use the gut – – Gut obstruction Short bowel (intestinal failure) High output enterocutaneous fistulae Non-functional gastrointestinal tract ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009; 28(4): 359 -479.

Contraindications to PN • Gut can be used: – Ability to consume and absorb adequate nutrients orally or by enteral tube feeding – Hemodynamic instability – *Ineffective and probably harmful in non-aphagic oncological patients in whom there is no gastrointestinal reason for intestinal failure. . * Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009; 28(4): 448.

Types of parenteral nutrition Central • • Amino acids ( > 5%) Dextrose ( > 20%) Lipids Includes vitamins, minerals, and trace elements Carrier of pharmaconutrients like glutamine or omega-3 fatty acids Osmolality ( > 700 m. Osm/kg H 2 O) Volume restriction Peripheral • • Total kcal limited by concentration and ratio to volume being administered (usually delivers between 1000 to 1500 kcal/day) The current formulations can now deliver the daily requirements of macro and micronutrients Osmolality < 700 m. Osm/kg No volume restriction

Types of parenteral nutrition • Central parenteral nutrition • Peripheral central parenteral nutrition PICC =peripherally inserted central catheter

Catheters Subclavian catheter (3 ports) PICC line catheters

Types of parenteral nutrition • Peripheral parenteral nutrition

Central venous access • Allows delivery of nutrients into the superior vena cava or right atrium • Osmolarity - traditional cut off > 860 m. Osm/L • Catheter differences : – According to duration of use – Various lengths, gauges, and number of ports – Catheters treated with antibacterials • Nutrient infusion via a dedicated catheter lumen • Pittiruti M et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters. Clin Nutr 2009; 28(4): 365 -7.

Formulations nitrogen sparing is shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours. • The different forms of PN packaging and delivery: – 2 Individualized – 2 Compounded – 1, 2 “All in One” • 1 Optimal 1. Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382. 2. Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2 nd ed 2005; 97 -107.

Formulation / Delivery Development phases of the PN container system Individualized delivery system Compounding / clean rooms Break seal “All in one” placed in multi-chambered bags • cheaper • stable • none to minimum contamination

Safety issues Protocols: 1. Compounding 2. Incorporation – additives 3. Delivery (access, rates of infusion, infusion pumps) Three in one bags: longer storage and less contamination In-line. Filters: 1. Fat emulsions 2. Three in one solutions 3. Microprecipitates

EN/PN monitoring parameters Metabolic Assessment • • Glucose Fluid and electrolyte balance Renal and hepatic function Triglycerides and cholesterol • • • Nutrient balance (calorie & protein intake) Body weight Nitrogen balance Plasma protein (albumin, pre-albumin) Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press, 1992 Ch 17: parenteral nutrition. Total Nutrition Therapy ver. 2, 2003; 311 -12.

Key monitoring points • Fluid balance – avoid fluid accumulation within 4 -5 days post op • Calorie balance • Gastric retention for enteral nutrition • Blood tests: – BUN high – dialyze – High triglycerides – lower lipid flow – Hyperglycemia – insulin • Weight once a week Jan Wernermann, “ICU Cookbook”. Franc-Asia Workshop, Singapore, 2003

OUTCOME IS DEPENDENT ON THE MONITORING PROCESS

Feeding Pathways Can the GIT be used? “Inability to use the GIT” Yes Tube feed No Oral “inadequate intake” Parenteral nutrition < 75% intake Short term Long term Peripheral PN Central PN More than 3 -4 weeks Yes No NGT Gastrostomy Nasoduodenal or nasojejunal Jejunostomy A. S. P. E. N. Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients, III: nutritional assessment – adults. J Parenter Enteral Nutr 2002; 26 (1 suppl): 9 SA-12 SA.

Calorie, protein, fluid balance form

Nutrient monitor form

Monitoring

DOCUMENTED OUTCOMES

Adequate intake in surgery patients Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients nutritionally assessed as high or low risk. Clinical Nutrition Service, St. , Luke’s

Nutrition team and intake Llido et al. Nutrition team supervision improves intake of critical care patients in a private tertiary care hospital in the Philippines: report from years 2000 to 2011 (for submission)

THANK YOU