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Nutritional support. Dr. Abdul- Monim Batiha Assistant Professor Critical Care Nursing Philadelphia university . Critically ill patients are often unable to eat because of 1- Endotracheal intubation. 2-The need for mechanical ventilation.
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Nutritional support Dr. Abdul-MonimBatiha Assistant Professor Critical Care Nursing Philadelphia university
Critically ill patients are often unable to eat because of 1-Endotracheal intubation. 2-The need for mechanical ventilation. 3-Altered level of consciousness as a result of severe trauma, major surgery or acute medical condition.
lack of nutrients may: 1-Alter the structure and function of the gut. 2-Increase the risk of entry and spread of intestinal bacteria.
Early nutritional support for critically ill patients has been advocated to: • 1-Promote the immune system recovery • 2-prevent as much as tissue breakdown • 3-nutritional deficit as possible
4-Improves patient outcomes. 5-Enhances recovery from illness.
Nutritional support means the provision of patient's dietary requirements
Nutritional support: includes: the use of artificial feeding methods such as tube feeding (enteral feeding), totalparenteral nutrition (TPN)and administration of intravenous fluids
Enteral feeding should be prescribed whenever oral intake is inadequate for the patient who has a functional gastrointestinal tract.
Enteral feeding has several advantages over total parenteral nutrition: • 1-EN has been shown to be easier, safer and cheaper than PN. • 2- EF maintains the structure and functional integrity of the gastrointestinal tract by intraluminal delivery of nutrients and preventing atrophic changes.
3-EF preserves the normal sequence of intestinal and hepatic metabolism, fat metabolism, lipoprotein synthesis and prevents cholestasis by stimulating bile flow.
4-Maintains normal insulin / glucagon ratios. 5-Reduction in septic complications with EF compared with PN. 6-EF improves systemic immunity and lower infection risk. 7- Prevents translocation of bacteria into the systemic circulation and reduce the incidence of sepsis.
On the other hand, intragastric EN often is complicated by intolerance, as indicated by elevated volumes of aspirated gastric residual. High gastric residual is a return of at least half of the hourly feeding rate. It is commonly accepted that high gastric residual volume enhances regurgitation and increases the risk for aspiration pneumonia.
Gastric residual is the amount of previous feeding remaining in the stomach
Gastric volumeduring intragastric feeding is determined by the balance between • The amount of infused formula plus • The endogenous secretions of saliva • And gastric juice and • The amount of fluid emptied from the stomach.
Fluids that commonly accumulate in the gastrointestinal tract of a tube fed patient include the • 1-Feeding formula, • 2-Swallowed saliva (> 0.8 L/ day), • 3-Gastric secretion (1.5 L/ day), • 4-Small bowel secretion regurgitated into the stomach (2.7 – 3 L/ day).
Critical care nurses play a crucial role before initiating NS to prevent high residual volume and other complications.
Critically ill patients with feeding tubes are therefore at higher risk for adverse outcomes than are other patients with feeding tubes
Most complications can be prevented with close monitoring and timely and accurate assessment of a patient’s tolerance to feeding.
Nurses are responsible for monitoring tolerance for the duration of therapy. A- Residuals should be checked for color, consistency and amount of last feeding still in the stomach, also for tolerance of enteral feeding .
B- Haemodynamic status should be monitored during nasogastric tube feeding.
Patients receiving isotonic formulas who are given too much fluid may show signs of fluid excess such as weight gain, edema and may develop dilutional hyponatremia.
On the other hand, patients receiving hypertonic, high-protein feedings who do not ingest enough fluid are at risk for life-threatening condition called tube-feeding syndrome, characterized by fluid-volume deficit, hypernatremia, hyperchloremia and azotemia.
So it is very important to monitor and assess fluid intake and output such as 1- body weight, 2-edema and respiratory rate, 3-blood urea nitrogen and other electrolytes.
The practice that is very important during feeding is measuring the gastric residual volumes:to help the nurse to confirm the placement of the tube, determine the nutritional tolerance and occurrence of gastric delay and if a high gastric residual volume can be detected early, it may be possible to prevent complications.
Mechanical complication • Gastrointestinal complications • Metabolic complications
Aspiration • Tube obstruction • Tube displacement
Aspiration is the most dangerous mechanical complication associated with EF. Pulmonary aspiration of EF with subsequent pneumonia is a frequent and serious complication of enteral nutrition in critically ill adults despite the presence of cuffed and properly inflated endotracheal tubes.
Aspiration pneumonia develops in 43% of patients on nasogastric tube feeding and in 56% of patients with a gastrostomy
A-When gastric motility is moderately or seriously impaired, feedings accumulate in the stomach along with gastric secretions and predispose to reflux and aspiration. Therefore, if a high gastric residual volume can be detected early, it may be possible to prevent aspiration.
Nosocomial pneumonia accounts for 13% to 18% of nosocomial infections and is the leading cause of death. Rates of nosocomial pneumonia and associated mortality are high in patients receiving mechanical ventilation and aspiration is the primary route by which bacteria enter the lung.
B-Other common causes of aspiration is tube placed in the trachea and regurgitation, this can be prevented by several techniques such as: 1-Checking the tube position before feeding
2-Elevating head of bed 30-60 degree during feeding and for one hour afterwards and if feeding is given by bolus. 3-No more than 330 ml should be given at one feeding to prevent excessive distension of stomach. 4-Also checking the gastric residual before each feed and if more than 150 ml, feeding should be held to prevent gastric distension.
Critical care nurses play a vital role in early detection of aspiration of gastric content into the pulmonary bed through the following methods:
food coloring method • Checking Ph • glucose strips
Using the food coloring method, by adding blue food coloring to feeding formulas to achieve a visible blue color, then suctioning tracheal secretions into transparent suction trap and examining the specimen for blue discoloration against a white background under full room lighting.
Checking pH is another method for detecting aspiration of gastric fluid into the lungs, because pulmonary fluid has a pH of approximately 7.6 while gastric pH is less than 4.
Moreover glucose strips can help to identify the fluid aspirated from the nasogastric tube as follows: a positive glucose reading is defined as a tracheal secretion specimen having a glucose concentration of ≥20 mg /dl measured using an automated glucose meter.
Presumptive aspiration is defined as having occurred when tracheal secretions showed either a positive glucose reading or observable blue discoloration.
On the other hand, measuring the glucose level is considered a more labored intensive technique because nurses should be trained and certified to use the bedside glucose testing equipment, in addition to the costs associated with the glucose strips.
Clinically, significant aspiration is defined as the occurrence of objective aspiration combined with one or more signs of systemic inflammation (temperature ≥ 37.8oC; heart rate ≥ 100 beats/min; leukocyte count ≥ 10.000 /cu mm)
and one or more signs of respiratory deterioration (respirations ≥ 20/min Pao2 < 60mmHg with Fio2 > 0.50) in addition to X ray
So it is very important to observe and measure the vital signs to determine the occurrence of aspiration and any alterations in the haemodynamic status that can lead to increasing the days remaining in the hospital and on nasogastric tube feeding
Nausea and vomiting, • Constipation • Delayed gastric emptying • Distension • Diarrhea
Nausea and vomiting associated with EFcan be caused by the following: 1-Tube migration into the esophagus, 2-Decreased absorption that lead to increase the gastric residual volume and hyperosmolar formula and excessive infusion of air. 3-An excessive accumulation of EF and gastric secretions increases the potential for regurgitation and vomiting.
Nursing interventions to reduce this complication include : 1-Checking residuals and holding feeding for one hour and rechecking if high gastric residual is found. 2-The head of the bed should be kept elevated. 3-When giving a bolus feeding, tubing should be pinched off when refilling syringe with formula and when giving continuous feeding, checking that the bag does not empty before closing off tubing is importance.
