NUTRISI ENTERAL

Dept. Anestesiologi & Terapi Intensif FK-USU/RSUP H.Adam Malik- MedanModul 12A

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*Nutrition Assessment CompletedDecision to initiate specialized nutrition supportFunctional GI tract ?YESNOENTERAL NUTRITIONPARENTERAL NUTRITIONGI-functionLong termGastrostomyJejunostomy

Short termNasogastricNasoenteric

normalcompromisedIntact nutrientsDefined formulaLong term/ fluid restrictionShort termCentral-PNPeripheral-PNGI-FUNCTION RETURN?YESNOAdequate NutritionInadequate NutritionAdequate NutritionPN-supplementationA.S.P.E.N - 1998

*Why patients should be fed enterally rather than parenterally,Maintenance of gut integrityPrevention of bacterial (or endotoxin) translocation.Maintenance of splanchnic blood flowMaintenance of adequate immune functions of the gut (GALT)Avoidance of catheter-related sepsisCost savingsWhen the gut works, use it, or loose it

*EVALUATE ENERGY + PROTEIN NEEDFUNCTIONAL GI-TRACT ?NO CONTRAINDICATIONS TO EN ?YESNOHighly catabolic state(major trauma, burn surgery,septic shock)?YESNOStart PNAre conditions to start EN present?YESNOStart continuous EN at 500 ml/24hStart PN and reassess daily for conditions to start ENGastric residual volume>200mlReduce infusion rate by 50% 4-6h, then progressive increase over 24-48 hMonitor gastric residual volume 2/dayMonitor gastric residual volume Administer prokinetics(cisapride, metoclopramide, erythromycin) Jolliet.P et al, Enteral nutrition in intensive care patients : a practical approach. Intensive Care Med 1998;24(8):848-859Increase flow rate by 250-500 ml/day

*ENTERAL NUTRITIONS : INDICATONSPatients unable or unwilling to consume adequate nutrition to meet metabolic requirement alone or with assistanceComplement insufficent intake or increase demand

*ENTERAL NUTRITION : INDICATIONSRequires total or partial GI tract function :AnorexiaApoplexiaComaSepsisTrauma / SurgeryTransition from Parenteral Nutrition

*ENTERAL NUTRITION : CONTRAINDICATIONSAbsoluteComplete bowel obstructionSevere small bowel ileus with abdominal distentionComplete inability to absorb nutrients through the GI tract

*ENTERAL NUTRITION : CONTRAINDICATIONRelativeSevere postprandial painShort bowel syndromeIntractable vomitingSevere diarrhea

*GASTRIC ACCESSGastric route preferredAdequate gastric motilityMinimum risk of aspirationGastric route contraindicatedDelayed gastric emptying ( gastroparesis )High risk for aspiration

*GASTRIC ACCESSGastric route advantages:Normal reservoir for foodEasy accessTolerates high osmotic loadsTolerates intermitens feedingsGastric acid destroy contaminentsCan be placed by nurses

*NASOGASTRIC TUBE : DISADVANTAGESShort term use onlyHigher risk for aspirationDifficult to confirm positionSmall boreNasopharyngeal trauma / irritationAccidental tube displacement

*PERCUTANEOUS ENDOSCOPIC GASTROSTOMY : ADVANTAGESThe same as for surgical gastrostomyNo surgery / less invasiveMinimal sedationDirect visualization< 30 minutes to place tubeLower cost

*SURGICAL GASTROSTOMYPerformed in operating roomIndicated when peg is contraindicated or during other surgical proceduresRequires general anesthesia and full surgical teamIn observation during recoveryMore expensive than PEG

*POST PYLORIC ACCESSIndication for post pyloric routePatient at risk for bronchial aspiration, gastric refluxGastric feeding contraindicated Gastric motility disorders : eg gastroparesisUpper gi tract condition : eg carcinoma stricture fistula

*POST PYLORIC ACCESSAdvantagesAllow earlier post op feedingLower risk of aspirationDisadvantagesSmall bore tubes prone to obstructionsTubes can be dislodge into stomachDifficult to maintain long termPotential for dumping syndromeRequres infusion pump

*Nasoenteric route Nasogastric, Nasoduodenal, Nasojejunal 2 -

*Nasoenteric Feeding Tube CompositionPeggi Guenter: Delivery System Administration of Enteral Nutrition, in Rombeau JL, Clinical Nutrition, Enteral and Tube Feeding,1997:244.

PVCSiliconePUREase to insertionTo stiff for comfortTo softAdequateAbility to aspirate gastric contentExcellentPoor to fairGoodPatient comfortVery poorExcellentGoodDurability/strengthStrong but brittleBreaks easilyExcellent/strong

*Naso Gastric Tube(NGT)

*Percutaneous routePEG, PEJ, combined nasogastric jejunalPEG, procedure of choice for ICU patients. [ 4-6 weeks]9-24Fr Relative CI, ascites, gastric cancer, gastric ulcer, previous laparotomy, coagulation disorder.Post-pyloric feeding PEJ.

*PEG

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*DURANTE OPERATIONEM

*Choosing the Feeding SiteCan the GI tract be used ?Parenteral NutritionTube feeding for more 2-4 weeks ?Nasoenteric TubeEnterostomy TubeRisk for pulmonary aspiration ?NGTNasoduodenal or nasojejunal tubeGastrostomyJejunostomyNoYesNoYesNoYesYesNo

*TIMINGEarly feeding refers to beginning nutrition within the first 24-48 hrs after an acute event(Should be initiated within 18 hours of injury in burn patient

EARLY

*Enteral Formulas : CategoriesPolymeric formulasCommercialBlenderizedOligomeric formulasDisease-specific formulasModular (concentrated protein and carbohydrate preparations)

*Benefits of Commercial FormulasCommercial Formulas

Uniform contentsSterileLow viscosityLactose freeDefined caloric densityBlenderized Formulas

Daily nutrient variabilityNon sterileHigh viscosityDoes not provide adequate caloric density

*Polymeric FormulasContain intact macronutrients and require digestionIntact proteinPolysaccharidesDisaccharidesPUFAMCTVitamine and MineralR/ Entrasol, Peptisol

*Commercial Polymeric Formulas :SelectionFeaturesProtein, caloric density and osmolality varyWith or without added fiberMost are gluten and lactose freeNutritionally complete in sfficient quantitiesPatient must haveFunctional GI tractNormal digestionNormal absorption

*Oligomeric Formula Categories(elemental, semi-elemental, hydrolyzed, chemically defined)Hydrolized macronutrients facilitate digestion and absorptionAmino acidsGlutamineArgininePeptidesMonosaccharidesDisaccharidesGlucose polymersPUFAMCTVitamins and Minerals

*Oligomeric Formulas :SelectionIndication for UseInflammatory bowel disease Pancreatic insufficiencyMalabsorptionShort Bowel syndromeRadiation enteritisearly enteral feedingIntolerance to polymeric formula

*Disease-Specific FormulasPulmonary diseaseGlucose intoleranceCancer induced weight lossHepatic insufficiencyCritical CareRenal failureHIV-AIDS

*Pulmonary disease (Chronic)Decreased CHO contentIncreased fat contentHigh Caloric densityIntact proteinsFiber supplementantioxidant

*Glucose IntoleranceLow CHO contentMonosaccharides (fructose)Glucose polymerMUFAAdded fiberR/ Diabetasol

*Cancer induced weight lossHigh protein and Zn to build muscleLow fat to early satietyLow in sucrose for better patient acceptanceHigh in fermentable fibersEicosapentaenoic acid (EPA)Antioxidants (vit-A, C, E and Se)Folate and Iron for anemia

*Hepatic DiseaseHigh caloric density with low sodium contentModerately high calorie nitrogen ratioHigh in BCAA, low in AAANon digestible soluble fiberLong chain FA, supplemental MCTFat soluble vitamins, Zn, folic acid and B-complex Low Cu, Fe and PhosphatR/ Hepatosol

*Critical Care (Mechanical Ventilation)Lung injury, SIRS, ARDSEPAGLAAntioxidantHigh caloric densityNo Arginine supplementation

Giving Arginine to septic patient is like putting gasoline on an already burning fire

*ENTERAL FORMULA : ORAL ADMINISTRATIONOral supplementationIndicated especially for patients with malnutrition or at risk for weight lossWhen given between meals, does not reduce intake of other foodsFrequently stimulates increased intake of other foodsThickened oral supplements are useful for patients with dysphagia

*ENTERAL FORMULA : TUBE FEEDINGTypeIntermittentContinous :24 hours / dayDuring part of the day or at nightInfusion methodGravityInfusion pump

*ENTERAL FORMULA : ADMINISTRATIONEnteral feedingIntermittent:Resembles normal feeding and digestion patters250 500 ml of formulaAdministered over 30 60 minutes5 8 times daily

*ENTERAL FORMULA : ADMINISTRATIONContinuousPlan IBeginning day one : 1000cc over 24 hoursProgress day two : 1500 cc over 24 hour day three: final vol according to needsPlan IIBeginning 25 cc / h ( first 12 hours )Progress 50 cc / h for next 12 hoursrate according to need

*ENTERAL FORMULA : ADMINISTRATIONInfusion pump indicationsSmall intestine feedingFluid restrictionRisk of aspirationNeed for precise flow rateNocturnal feedingInfants and small children

*Gravity infusion indicationSuitable for intermittent feedingAmbulatory patientsGastric feeding

*ENTERAL FORMULA : ADMINISTRATIONSummaryIntermittent feedingContinous feeding

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Intermittent (bolus)Administering tube feeding naso gastric tube, gastrostomy head up position 300 start gastric feeding of 150-200ml over 20-40 minutes, increase by 50-100ml each feeding as tolerated to goal followed by 30 ml warm water flush check residuals before next feeding (up to half) for sign of intolerance (diarrhea, vomiting), reduce to last tolerated step, evaluate clinically.

*Continuous (drip infusion)Intragastric, duodenal, jejunalStart at 30-50 ml/hr isotonic formulaIncrease by 30-50/hr every 6-8 hours to goalMaximum 100-150ml/hrMost tube fedings are tolerated at full strengthReduce risk ( retention, aspiration)followed by 30 ml warm water flushfor sign of intolerance (diarrhea, vomiting), reduce to last tolerated step, evaluate clinically.

*Continuous drip infusion

*Monitoring,Metabolic, gastrointestinal, mechanical assessmentRoutine dayli evaluation of intake,output, weightAcutely ill patients require daily to weekly serum electrolyte, glucose, BUN, Cr, Ca++, Mg++, Ph.Stable patients require weekly-monthly laboratory studiesElevate head of bed 300 during feedingCheck stomach for high residuals to minimize aspiration risk

*Metabolic : overhydration, dehydration, undernutrition, hyperglycemia, electrolyte imbalanceGastrointestinal : nausea, vomiting, constipation abd. discomfort, diarrheaMechanical : misplaced, clogged feeding tube airway, GI tract injury with NG/NJ tube placement.Infectious : peritonitis, exit site infection, sinusitis, aspiration pneumonia

Complications

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Nutrisi Enteral Skill Menghitung kebutuhan Nutrisi pasien

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