SUPPLEMENTAL NUTRITION

1. SUPPLEMENTAL NUTRITION PROS, CONS, AND CHALLENGES Sue Kane, SA-C, Clinical Coordinator Applied Medical Technology, Inc.

2. Malnutrition As a general rule, enteral or parenteral feeding is advised when a patient is unable to eat for 7-14 days or longer. Malnutrition is a common problem increasing morbidity and mortality of hospitalized patients and is often not recognized throughout the hospital stay. This may affect recovery from illness, surgery and trauma and can result in poor post operative results as well as wound healing and post operative complications. .

3. Protein Malnutrition Usually caused by inadequate nutrient intake in conjunction with a stress response Causes: Chronic diarrhea, renal dysfunction, infection, hemorrhage, trauma, burns, critical illness Results: Marked hypoalbuminemia, anemia, edema, muscle atrophy, delayed wound healing, impaired immunocompetence

4. Protein-Calorie Malnutrition Typically in the emaciated, elderly and chronically ill patient Results: Weight loss, reduced basal metabolism, depletion of subcutaneous fat and tissue turgor, bradycardia, hypothermia

5. Risk Factors of Malnutrition • Recent surgery or trauma • Sepsis • Chronic illness • Anorexia/eating disorders • Dysphagia • Recurrent nausea, vomiting or diarrhea • Pancreatitis • Inflammatory bowel disease • Gastrointestinal fistulas

6. Consequences of Malnutrition • Longer recovery time • Impaired defenses and sepsis • Impaired wound healing • Anemia • Impaired G.I tract function • Muscle atrophy • Impaired cardiac function • Impaired renal function • Impaired respiratory function • Brain dysfunction • Atrophic skin

7. Benefits of early nutrition • Less time on mechanical ventilation • Reduce infections • Better wound healing • Shorter hospital stays • Maintaining bowel mucosa integrity • May support normal immune function • Decrease translocation of gut bacteria

8. OVERVIEW The gastrointestinal (GI) tract is the route by which the body is supplied with water, electrolytes, and nutrients There are many clinical conditions in which the GI tract is temporarily or permanently unavailable, not functioning, or damaged. In these situations, the patient’s health is seriously jeopardized. Accessing the GI tract can be done intravenously or by tube feeding. Tubes; nasogastric (NG), nasojejunal (NJ), gastrostomy (G-tube), jejunal (J-tube), and gastrojejunal (GJ-tube) are used to provide the body with nutrition, perform gastric decompression, and to evaluate/treat GI bleeding. Each of these tubes has a specific insertion technique, specific advantages and disadvantages, and complications. This presentation will provide a basic review of the anatomy and function of the GI tract and discuss the use of gastric tubes for enteral nutrition. Specific radiologic techniques that are used for insertion will be discussed and described.

9. Review of G.I. Tract • The gastrointestinal (GI) tract is involved in providing the body with water, electrolytes, and nutrients. In order for this to happen, food must be transferred through the GI tract, there must be a secretion of digestive juices, there must be absorption of water, electrolytes, and nutrients, and each part of the GI tract is designed to carry out one of those functions.

10. SUPPLEMENTAL NUTRITION • Oral – preferred method • Intravenously (Parenteral) used primarily for non functioning GI tract • Via tube (Enteral) Preferred because it facilitates maintenance of intestinal structure and function, improves immunity, and avoids catheter related complications associated with parenteral nutrition. Accepted to be safer, associated with better patient outcomes and more economical than parenteral. • nasal • enterostomy

11. Gastrointestinal Access • Nutrition • Gastric Decompression • Evaluating/Treating patients with gastrointestinal bleeding

12. Parenteral vs. Enteral • Catheter placed in vein in arm or chest • Hickman catheter, Broviac, PICC line, single, double or triple lumen catheters • Nasogastric - Nose to fundus of stomach. A catheter tip syringe or suction tube attaches. • Nasoduodenal/Nasojejunal-Nose to 3rd portion of the duodenum or the Ligament of Treitz in the jejunum. • Gastrostomy - Abdominal wall to the stomach. • Gastrojejunostomy - Abdominal wall to the stomach and the tube is advanced into the jejunum. Has 3 ports, 1 for the balloon, 1 for the gastric fluids to be removed, and 1 for nutrition and medicines to be administered directly into the jejunum. • Jejunostomy - Abdominal wall to the jejunum. *In the setting of a functional gut, enteral feeding is preferred to parenteral options.

13. Parenteral - PPN (Peripheral)/TPN (Central) Advantages Disadvantages/Complications • Needed when GI tract is non –functioning • Non patent G.I. Tract prior to surgery • Post gastrointestinal surgery • Short Gut Syndrome - A condition in which the bowel is not as long as normal, either because of surgery or because of a congenital defect. Because the bowel has less surface area to absorb nutrients, it can result in malabsorption syndrome • Catheter associated infections • Air Embolism • Circulatory overload • Hyperglycemia • Hypoglycemia • Catheter Occlusion • Pneumothorax (central line) • Venous thrombosis • Infection • Fluid and electrolyte complications

14. Enteral -Nasogastric Indications • Intact gag reflex • No esophageal reflux • Normal gastric emptying • Stomach uninvolved with primary disease

15. Contraindications • NG tube feeding is inadvisable in patients with basilar skull fractures, severe facial fractures especially to the nose and obstructed esophagus, esophageal varices, and/or obstructed airway. • Intestinal obstruction • Gastric bypass surgery

16. Nasogastric feeding tubes NG Advantages • Nutrition • Avoid general anesthesia • Avoid surgical procedure • Low incidence of complications • Reduce abdominal distention • Speeding up the return of bowel function. • Decrease the chance of wound dehiscence and hernia post op • Decrease the chance of wound separation and infection post op • Easy tube insertion • Larger reservoir capacity in stomach

17. Disadvantages and complications • Highest risk of aspiration • Abdominal distention • X-Ray or fluroscopy for confirmation of tube placement • Suited only to short term (6 weeks) • Esophageal perforation • Intracranial placement of the tube – patients with severe head trauma, maxillofacial injury • Pneumothorax • Diarrhea • Fluid and electrolyte imbalances • Hyperglycemia • Nose bleed • Sinusitis • Tube migration • Block easily • Patient self conscious of tube

18. Methods of checking tube placement • Air insufflation and auscultation of the epigastrium • Aspiration of gastric contents • pH testing • X-ray confirmation (most reliable way to determine position of tube) • *Tube should be marked with permanent ink at the point of entry after x-ray confirmation

19. Nasojejunal tubes Many clinicians believe that enteral nutrition delivered to the small bowel is a better choice than feedings delivered to the stomach, and will place a NJ feeding tube. This type of feeding tube is more difficult to place than a NG tube, but its proponent’s say that it decreases the risk of aspiration, may provide more calories, and the feeding schedule will be subject to fewer interruptions. Both the jejunum and the stomach can be safely used to deliver calories, the differences between the two types of tubes are minimal, both can be effective, and the decision as to which one to use depends on the skill of the practitioner and the potential tolerance of the patient.

20. The NJ tube can be placed using an endoscope or by using fluoroscopy. When choosing fluoroscopy the practitioner must weigh the exposure to radiation, the need for transport to the radiology department, patient safety, and cost. Some practitioners have reported success by placing the NJ tube in the stomach and allowing it to spontaneously move into the small bowel. Magnetically guided tubes have also been used as well such as the Cortrak System.

21. Nasoduodenal/Nasojejunal Indications • Gastroparesis or • impaired gastric • emptying • Esophageal reflux

22. Nasoduodenal/Nasojejunal Disadvantages Advantages • Potential GI intolerance (bloating, cramping, diarrhea) • May require endoscopic placement of nasoenteric tube • Patient self conscious due to appearance of tube • Tube displacement and potential aspiration • X-Ray or fluroscopy for confirmation of tube placement • Suited only to short term (6 weeks) • Esophageal perforation • Intracranial placement of the tube – patients with severe head trauma, maxillofacial injury • Pneumothorax • Nose bleed • Sinusitis • Reduced aspiration risk compared to NG • Nutrition • Avoid general anesthesia • Avoid surgical procedure • Low incidence of complications • Reduce abdominal distention • Speeding up the return of bowel function. • Decrease the chance of wound dehiscence and hernia post op • Decrease the chance of wound separation and infection post op

23. It is important to secure feeding tubes. The incidence of accidental loss is high particularly in the critically ill who often have altered levels of consciousness.

24. Nutritional support improves clinical outcomes. Frequent tube dislodgement may prevent effective enteral feeding. In a prospective study, 21 patients received NG feeding over 173 days. Only 46% of volume feed prescribed was delivered. Each patient required between 2-11 tubes and 85.9% dislodgements were due to patient removal. Less than half of EN patients achieve their caloric goal *Prospective audit Leeds Teaching Hospitals NHS Trust/Faculty of Health,Leeds Metropolitan University, Leeds, UK Nov. 2008

25. Securing Nasal Feeding Tubes OPTIONS • Tape – Inexpensive Disadvantages: Skin breakdown, uncomfortable, risk of nasal injury • Suturing – Inexpensive, more effective than tape Disadvantages: Uncomfortable, potential damage to nasal septum if pulled by patient or clinician • Bridling (old school) – Effective, inexpensive Disadvantages: Uncomfortable to place, difficult to place, securing tube is challenging • Bridling (AMT Bridle) – Easy to use, safe, comfortable, cost effective, FDA approved device

26. Securement of feeding tubes A New Method The AMT Bridle is an umbilical tape system placed with magnets that attract in the nasopharyx to deliver the umbilical tape through the nares. The NG tube is then secure with the umbilical tape in an appropriate size clip. An Old Method A red rubber catheter, usually an 8fr, was placed through the nares on each side, retrieved in the nasopharynx with forceps, tied together, advanced, and then tied around the NG tube.

27. Clinical References Regarding Bridling of Feeding Tubes “Routine Bridling of Nasojejunal tubes is a safe and effective method of reducing dislodgement in the ICU. This simple practice can be performed with low morbidity and may improve enteral nutrition and reduce exposure to procedural complications.” Christopher W. Seder, MD; Randy Janczyk, MD: NCP Nutrition in Clinical Practice 2008-2009; 23 (6) 651-654 “Nasal bridling decreases feeding tube dislodgement and may increase caloric intake in the surgical intensive care unit: A randomized, controlled trial.” Christopher W. Seder, MD; William Stockdale, RN; Linda Hale, RN; Randy J. Janczyk, MD, FACS : Critical Care Medicine 2010, Vol. 38 No.3 "Use of Nasal Bridle Prevents Accidental Nasoenteral Feeding Tube Removal.” Scott R. Gunn, MD, Barbara J. Early, RN; Mazen S. Zenati, MD, MPH, PhD; Juan Ochoa, MD, FACS: JPEN Journal of Parenteral and Enteral Nutrition 2009; 33(1):50-54

28. IMPROVE OUTCOMES • Optimize caloric intake • Reduced risk of aspiration • Reduce radiographic exposure • Eliminate skin breakdown due to • adhesives • Delay PEG placement or • conversion to TPN • Reduce risks of reinsertion • Pneumothorax • Esophageal perforation • Tracheal / Bronchial injury • DECREASE COSTS • Cost of x-ray or fluoroscopy • Cost of extended length of stay • due to sub-optimal nutrition • Cost of new nasal tube, formula • and supplies • Cost of clinicians’ time to replace • nasal tube

29. Preventing blocked tubes Routine flushing with warm water can prevent clogging of feeding tubes. Acidic products can cause proteins in formula to coagulate. You may need to flush before and after administering solutions. As an alternative, pancreatic enzymes with sodium bicarbonate may be used. Check with physician.

30. Gastrostomy placed laparoscopically, operatively, or percutaneouslyIndications • Swallowing dysfunction and subsequent impairment of ability to consume oral diet • Intact gag reflex; no esophageal reflux • Long term feeding; normal gastric emptying • Stomach uninvolved with primary disease • Patients with an inability to ingest adequate nutrients to meet metabolic demands

31. Percutaneous Endoscopic Gastrostomy (PEG) Push or pull method using an endoscope under local anesthesia and conscious sedation It is a safer and more cost effective method than surgical placed gastrostomies and has a lower mortality rate May be replaced with low profile device usually after 6 weeks

32. Gastrostomy Disadvantages/Complications Advantages • May be used immediately or within hours of placement • may be used for long-term support • may be used in presence of significant disease of upper GI tract (esophagus, stomach and duodenum) • percutaneously placed tubes avoid risks of general anesthesia • laparoscopically placed tubes allow patient to return home same day as placed • Larger reservoir capacity in stomach • Peritonitis • Stoma care needed • Gastric perforation • Hemorrhage requiring transfusion • Deep stoma infection • Septicemia • Aspiration • Wound infection • Peristomal leakage/skin excoriation • Tube dislodgement • Potential fistula after tube is removed • Surgery needed for surgical gastrostomies

33. Jejunostomy A Jejunostomy tube provides nutritional support with the tube placed directly through the abdominal wall into the jejunum. It is particularly useful in patients who are at high risk of aspiration of feedings delivered to the stomach, patients with non-functional stomachs, patients with esophageal carcinoma or chronic pancreatitis, and patients who have had a total gastrectomy.

34. Jejunostomy - Indications • Long term feeding • High risk of aspiration • Esophageal reflux • Inability to access upper GI tract • Gastroparesis or impaired gastric emptying • Gastric dysfunction due to trauma or surgery

35. Jejunostomy Advantages Disadvantages • Potential GI intolerance • Stoma care needed • Peritonitis • Stoma care needed • Hemorrhage requiring transfusion • Deep stoma infection • Septicemia • Wound infection • Peristomal leakage/skin excoriation • Tube dislodgement • Potential fistula after tube is removed • Tube occlusion with small bore tube • Surgery needed for surgical jejunostomies • Reduced risk of aspiration • Placed adjunctly with GI surgery • No surgery needed for percutaneous endoscopic jejunostomy • PEJ less costly than surgical jejunostomy

36. Gastrojejunostomy tube When gastroesophageal reflux is present there is a high risk of aspiration of gastric secretions and enteral feeding. In this case a G-J tube is used to aspirate gastric contents and feed into the jejunum. The G-J tube is placed into the stomach and secured by a balloon. There is an extension of the tube with holes that is guided into the jejunum for feeding. There are two ports located on the outside of the tube.

37. Pros and Cons of Enteral Feeding Technique

38. Conclusion Using a team approach, it is important to start enteral feeding as early as possible. Providing early feeding will result in the best outcome for malnourished and critically ill patients resulting in shorter hospital stays and improving their overall health. Review patient goals daily and use recommended interventions to avoid complications.

39. Bibliography • Christopher W. Seder, MD; William Stockdale, RN; Linda Hale, RN; Randy J. Janczyk, MD, FACS, “Nasal bridling decreases feeding tube dislodgement and may increase caloric intake in the surgical intensive care unit: A randomized, controlled trial.” Critical Care Medicine 2010, Vol. 38 No.3 • Scott R. Gunn, MD, Barbara J. Early, RN; Mazen S. Zenati, MD, MPH, PhD; Juan Ochoa, MD, FACS, "Use of Nasal Bridle Prevents Accidental Nasoenteral Feeding Tube Removal."JPEN Journal of Parenteral and Enteral Nutrition 33(1):50-54,2009 • Chris Winkleman, PhD, RN, CCRN, Kathleen Best, RD, LD, CNSD, Formula for success: Deliver enteral nutrition using best practices, American Nurse Today, 2009 • Coupe, AM, Donnellan, CF, Copeman, J. ,How effective is enteral nutrition via naso-gastric tubes in patients with alcohol liver disease?, roceedings of the Nutrition Society, 68 (OCE1), E7, 2009 • Christopher W. Seder, MD; Randy Janczyk, MD, "The Routine Bridling of Nasojejunal Tubes Is a Safe and Effective Method of Reducing Dislodgement in the Intensive Care Unit.“, NCP Nutrition in Clinical Practice 2008-2009; 23 (6) 651-654. • RX Kinetics, Management of Enteral Nutrition, www.rxkinetics.com/tpntutorial2_2.html, 2008 • Nirav Thosani, Complications of Total Parenteral Nutrition, www.sci.med.nutrition • McClave, S., Critical Care Nutrition: The Importance of Delivering Early Enteral Feeding, American Society for Parenteral and Enteral Nutrition, 2007 • Dana Bartlett, RN, MSN, CSPI & J. Werner R.T. (R), , Enteral Feeding Tubes and Gastric Decompression Tubes, adiographic Imaging CEU Source, 2006 • Williams, Teresa A., Leslie, Gavin D., A review of the nursing care of enteral feeding tubes in critically ill adults: Part I, ntensive and Critical Care Nursing 2004 • Enteral and Parenteral Nutrition Support, University of Wisconson, Green Bay, http://www.uwgb.edu/ laceyk/ NutSci486/ Chapter23.ppt 1.8Mb, 2004 • James A. DiSario, MD, Wililam N. Baskin, MD, Russel D. Brown, MD, MarkH. DeLegge, MD, John C.Fang, MD, Gregory G Ginsberg, MD, Stephen A. McClave, MD, Endoscopic approaches to enteral nutritional support, Gastrointestinal Endoscopy, Volume 55, No.7 2002 • Pearce,C,B., Duncan, H.D., Enteral Feeding. Nasogastric, Nasojejunal, Percutaneous Endoscopic Gastrostomy, or Jejunostomy: Its Indications and Limitations, Post Graduate Medical Journal 2001 • Susan Bussell, R.D., Kim Donnelly, R.Ph., Scott Helton, M.D., Susan Kracke, R.Ph., Robert Labbe, Ph.D., Edward Lipkin, M.D., Ph.D., Jill McCormick, M.S.,R.D., Patricia Riley, R.D., Megan Veldee, M.S., R.D., Sarah Washburn M.S., R.D.,, A Resource Book for Delivering Enteral and Parenteral Nutrition for Adults, Clinical Nutrition - University of Washington Academic Medical Centers http://healthlinks.washington.edu/nutrition/section5.html, 1997