Implementing Enteral Nutrition Therapy: Enteral Access

1. Implementing Enteral Nutrition Therapy:Enteral Access

2. Objectives • To describe the benefits of enteral nutrition therapy • To review indications and contraindications of enteral nutrition • To describe access routes for enteral nutrition infusion • To describe the advantages and disadvantages of various enteral access routes

3. Enteral Nutrition Therapy: Benefits • Maintains gastrointestinal structure and function • Reduces translocation of toxins and possibly bacteria • Less expensive than parenteral nutrition therapy • Fewer complications

4. “If the gut works, use it.”

5. Enteral Nutrition: Indications • Patients unable or unwilling to consume adequate nutrition to meet metabolic requirements alone or with assistance • Complement insufficient intake or increased demand

6. Enteral Nutrition: Indications Requires total or partial GI tract function • Anorexia • Apoplexy • Coma • Sepsis • Trauma/surgery • Transition from parenteral nutrition

7. Enteral Nutrition: Contraindications Absolute • Complete bowel obstruction • Severe small bowel ileus with abdominal distention • Complete inability to absorb nutrients through the GI tract

8. Enteral Nutrition: Contraindications Relative • Severe postprandial pain • Short bowel syndrome • Intractable vomiting • Severe diarrhea

9. Gastric Access Gastric Route Preferred • Adequate gastric motility • Minimum risk of aspiration Gastric Route Contraindicated • Delayed gastric emptying (gastroparesis) • High risk for aspiration

10. Gastric Access Gastric Route Advantages • Normal reservoir for food • Easy access • Tolerates high osmotic loads • Tolerates intermittent feedings • Gastric acid destroys contaminants • Can be placed by nurses

11. Gastric Feeding Techniques Rugeles S, et al. Universitas Medica 1993;34(I):19-23

12. Nasogastric Tubes 8 Fr, stylet,opaquebolus, 45" 12 Fr,opaque, 36" 12 Fr,clear, 36"

13. Nasogastric Tube: Disadvantages • Short-term use only • Higher risk for aspiration • Difficult to confirm position • Small bore • Nasopharyngeal trauma/irritation • Accidental tube displacement

14. Percutaneous Endoscopic Gastrostomy: PEG Tubes Rigid Flexible Minard G. Nutr Clin Prac 1994;9:172-182

15. Percutaneous Endoscopic Gastrostomy: Advantages • The same as for surgical gastrostomy • No surgery / less invasive • Minimal sedation • Direct visualization • < 30 minutes to place tube • Lower costs

16. Percutaneous Endoscopic Gastrostomy: Placement Criteria • Adequate passage for endoscope • Ease in identifying safe site • Ease in determining a safe tract • Functioning GI tract • Absence of ascites / morbid obesity Stellato TA, et al. Ann Surg 1984;200:46-50Lee M, et al. Clin Radiol 1991;44:332-334

17. Surgical Gastrostomy • Performed in operating room • Indicated when PEG is contraindicated or during other surgical procedures • Requires general anesthesia and full surgical team • In observation during recovery • More expensive than PEG

18. Gastrostomy: Low-Profile Tube

19. Post-pyloric Access Indications for post-pyloric route • Patient at risk for bronchial aspiration, gastric reflux • Gastric feeding contraindicated – Gastric motility disorders; e.g., gastroparesis – Upper GI tract condition; e.g., carcinoma, stricture, fistula

20. Disadvantages • Small bore tubes, prone to obstruction • Tubes can be dislodged into stomach • Difficult to maintain long term • Potential for dumping syndrome • Requires infusion pump • Advantages • Allows earlier post-op feeding • Lower risk of aspiration Post-pyloric Access Montecalvo MA, et al. Crit Care Med 1992;20:1377-1387

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

22. Nasal Access: Tubes Nasogastric Nasoduodenal / Jejunal • Easy • Short term • Y-Port • Small bore • Weighted tip • Metal guidewire

23. Post-pyloric Enteral Nutrition: Indications • History / risk of reflux or aspiration • Gastric motility disorders • Upper GI tract fistulae • Acute pancreatitis

24. Post-pyloric Enteral Nutrition:Advantages • Easily accessible • Less invasive • Lower risk of aspiration • Manual, fluoroscopic, or endoscopic placement

25. Post-pyloric Enteral Nutrition:Disadvantages • Placement can be difficult to achieve and maintain • Requires x-ray confirmation • Short term use only • Nasopharyngeal trauma / irritation • Small bore tube

26. Jejunostomy Feeding: Indications • Feeding contraindicated for upper GI tract • Gastric motility disorders • History / risk of reflux or aspiration

27. Nutrition by Jejunostomy: Disadvantages • Small bore tube • Placement can be difficult to achieve and maintain • Difficult to maintain for long term

28. Percutaneous Endoscopic Jejunostomy • Tube placed with or without existing PEG • Requires endoscopy • Placed distal to Ligament of Treitz Bumpers HL, et al. Surg Endosc 1994;8:121-123

29. Nasal Access: Multilumen Tubes

30. Can the GI tract be used? No Yes Parenteral Nutrition Tube feeding for more than 6 weeks? No Yes Nasoenteric Tube Enterostomy Tube Risk for pulmonary aspiration? No Yes No Yes Nasogastric Tube Nasoduodenalor nasojejunal tube Gastrostomy Jejunostomy Choosing the Feeding Site

31. Summary • Enteral nutrition should always be the first option considered • Gastric access is the first choice • Use post-pyloric route if gastric access not possible • Nasogastric route should be used for short term feedings • Surgical or percutaneous enterostomies should be the choice for long term cases and for laparotomy patients