TPN and EN Any guidelines

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TPN and ENAny guidelines
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Sorry

• Now,there is no ENTPN guideline in china
• Maybe is coming,really coming

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Peking nutrition forum

• We should kown what is nutrition support
• Transfusion vamin and lipid, is really nutrition
  support?
• When, why, how, and who should?
• How to evaluate?
• Methods and approach?

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Westen guidelines

• Guidelines for enteral feeding in adult hospital
  patients Gut,200352(Suppl VII)vii1vii12
• Parenteral Nutrition Guidelines,A consensus
  document for the safe delivery of Parenteral
  Nutrition in Adult Patients in Queensland
  Hospitals,2004
• ESPEN guidelines on artificial enteral nutrition
  PEG Clinical Nutrition,200524848861
• Parenteral Nutrition Guidelines (Adults),Oxford
  Radcliffe Hospitals NHS Trust Nutrition Support
  Team,Version 2.7,August 2004 (revision date
  August 2005)

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Guidelines for enteral feeding in adult hospital
patients-Summary of recommendations

• Indications for enteral feeding
• Health care professionals should aim to provide
  adequate nutrition to every patient unless
  prolongation of life is not in the patients best
  interest (grade C).
• It should be hospital policy that the results of
  an admission nutritional screening are recorded
  in the notes of all patients with serious illness
  or those needing major surgery (grade C).

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Summary of recommendations

• Indications for enteral feeding
• Artificial nutrition support is needed when oral
  intake is absent or likely to be absent for a
  period 57 days. Earlier instigation may be
  needed in malnourished patients (grade A).
  Support may also be needed in patients with
  inadequate oral intake over longer periods
• Decisions on route, content, and management of
  nutritional support are best made by
  multidisciplinary nutrition teams (grade A).

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Summary of recommendations

• Indications for enteral feeding
• ETF(enteral tube feeding) can be used in
  unconscious patients, those with swallowing
  disorders, and those with partial intestinal
  failure. It may be appropriate in some cases of
  anorexia nervosa (grade B).
• Early post pyloric ETF is generally safe and
  effective in postoperative patients, even if
  there is apparent ileus (grade A).
• Early ETF after major gastrointestinal surgery
  reduces infections and shortens length of stay
  (grade A)

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Summary of recommendations

• Indications for enteral feeding
• In all post surgical patients not tolerating oral
  intake, ETF should be considered within 12 days
  of surgery in the severely malnourished, 35 days
  of surgery in the moderately malnourished, and
  within seven days of surgery in the normally or
  over nourished (grade C).
• If there are specific contraindications to ETF,
  parenteral feeding should be considered. If
  patients are takinggt50 of estimated nutritional
  requirements, it may be appropriate to delay
  instigation of ETF (grade C).
• ETF can be used for the support of patients with
  uncomplicated pancreatitis (grade A).

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Summary of recommendations

• Ethical issues
• ETF should never be started without consideration
  of all related ethical issues and must be in a
  patients best interests (grade C).
• ETF is considered to be a medical treatment in
  law. Starting, stopping, or withholding such
  treatment is therefore a medical decision which
  is always made taking the wishes of the patient
  into account.
• In cases where a patient cannot express a wish
  regarding ETF, the doctor must make decisions on
  ETF in the patients best interest. Consulting
  widely with all carers and family is essential.

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Summary of recommendations

• Access techniques
• Fine bore (58F) nasogastric (NG) tubes should be
  used for ETF unless there is a need for repeated
  gastric aspiration or administration of high
  viscosity feeds/drugs via the tube. Most fibre
  enriched feeds can be given via these fine bore
  tubes (grade A).
• NG tubes can be placed on the ward by experienced
  medical or nursing staff, without x rays to check
  position. Their position must be checked using pH
  testing prior to every use (grade A).
• The position of a nasojejunal (NJ) tube should be
  confirmed by x ray 812 hours after placement.
  Auscultation and pH aspiration techniques can be
  inconclusive (grade A).

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Summary of recommendations

• Access techniques
• NG tube insertion should be avoided for three
  days after acute variceal bleeding and only fine
  bore tubes should be used (grade C).
• There is no evidence to support the use of
  weighted NG tubes, in terms of either placement
  or maintenance of position (grade A).
• Long term NG and NJ tubes should usually be
  changed every 46 weeks swapping them to the
  other nostril (grade C).

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Summary of recommendations

• Access techniques
• Gastrostomy or jejunostomy feeding should be
  considered whenever patients are likely to
  require ETF for more than 46 weeks (grade C) and
  there is some evidence that these routes should
  be considered at 14 days (grade B).
• Suitability for gastrostomy placement should be
  assessed by an experienced gastroenterologist or
  member of a nutrition support team. Expert advice
  on the prognosis of swallowing difficulties may
  be needed (grade C).
• In patients with no risk of distal adhesions or
  strictures, gastrostomy tubes with rigid internal
  fixation devices can be removed by cutting them
  off close to the skin, pushing them into the
  stomach, and allowing them to pass spontaneously
  (grade A).

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Placing a nasogastric tube

• Explain the procedure to the patient.
• Mark the tube at a distance equal to that from
  the xiphisternum to the nose via the earlobe
  (5060 cm).
• Lubricate the tube externally with gel/water and
  internally with water if a guidewire is present.
  Check the guidewire moves freely.
• Check nasal patency by sniff with each
  nostril occluded in turn. The clearer nostril can
  be sprayed with lignocaine to minimise
  discomfort.
• Sit the patient upright with the head level.
  Slide the tube gently backwards along the floor
  of the clearer nostril until visible at the back
  of the pharynx (1015 cm).

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Placing a nasogastric tube

• If the patient is cooperative, ask them to take a
  mouthful of water and then advance the tube 510
  cm as they swallow.
• Repeat the water swallow/advance until the preset
  mark on the tube reaches the nostril.
• Withdraw the tube at any stage if the patient is
  distressed, coughing, or cyanosed.
• If there is difficulty passing the tube, ask the
  patient to tilt their head forwards or turn it to
  one side.
• Once in place, remove any guidewire and secure
  carefully.
• Check position of the tube before use (this does
  not usually require an x ray).
• Document tube insertion in the patients notes.

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Summary of recommendations

• Feed administration
• Giving enteral feed into the stomach rather than
  the small intestine permits the use of hypertonic
  feeds, higher feeding rates, and bolus feeding
  (grade A).
• Starter regimens using reduced initial feed
  volumes are unnecessary in patients who have had
  reasonable nutritional intake in the last week
  (grade A). Diluting feeds risks infection and
  osmolality difficulties.
• Both inadequate or excessive feeding may be
  harmful. Dietitians or other experts should be
  consulted on feed prescription (grade C).

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Summary of recommendations

• Feed administration
• If no advice is available, 30 ml/kg/day of
  standard 1 kcal/ml feed is often appropriate but
  may be excessive in undernourished or
  metabolically unstable patients (grade C).
• When patients are discharged to the community on
  continuing ETF, care must be taken to ensure all
  community carers are fully informed and that
  continuing prescription of feed and relevant
  equipment is in place (grade C).

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Summary of recommendations

• Complications of enteral feeding
• Close monitoring of fluid, glucose, sodium,
  potassium, magnesium, calcium, and phosphate
  status is essential in the first few days after
  instigation of ETF (grade C).
• Life threatening problems due to refeeding
  syndrome are particularly common in the very
  malnourished and there are also risks from over
  feeding shortly after major surgery or during
  major sepsis and/or multiorgan failure (grade C).
• To minimise aspiration, patients should be fed
  propped up by 30or more and should be kept
  propped up for 30 minutes after feeding.
  Continuous feed should not be given overnight in
  patients who are at risk (grade C).

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Summary of recommendations

• Complications of enteral feeding
• Any drugs administered via an ETF tube should be
  liquid and should be given separately from the
  feed with flushing of the tube before and after
  (grade C).
• Loosening and rotating a gastrostomy tube may
  prevent blockage through mucosal overgrowth and
  may reduce peristomal infections (grade C).
• In patients with doubtful gastrointestinal
  motility, the stomach should be aspirated every
  four hours. If aspirates exceed 200 ml, feeding
  policy should be reviewed (grade C).

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Summary of recommendations

• Complications of enteral feeding
• Continuous pump feeding can reduce
  gastrointestinal discomfort and may maximise
  levels of nutrition support when absorptive
  capacity is diminished. However, intermittent
  infusion should be initiated as soon as possible
  (grade A).
• Simultaneous use of other drugs, particularly
  antibiotics, is usually the cause of apparent ETF
  related diarrhoea (grade A).
• Fibre containing feeds sometimes help with ETF
  related diarrhoea, as will breaks in the feeding
  of 48 hours (grade B).

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Summary of recommendations

• Complications of enteral feeding
• Careful measures are needed to avoid bacterial
  contamination of feeds which can give rise to
  sepsis, pneumonia, and urinary tract infections,
  as well as gastrointestinal problems (grade A).
• Avoiding gastric acid suppression and allowing
  breaks in feeding to let gastric pH fall will
  help prevent bacterial overgrowth during ETF
  (grade A).

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Malnutrition universal screening tool (MUST)
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TPN Guidelines (Adults),2005

• Oxford Radcliffe Hospitals NHS Trust
• For patient selection, duration of treatment,
  monitoring of results and documentation.
• Where a fully operational Nutrition Support Team
  (NST) is in place, reduced parenteral nutrition
  (PN) related complications (line and metabolic),
  decreased morbidity, improved nutrient intake,
  improved clinical outcomes, reduced costs and
  decreased length of stay
• intended to be a working document to help achieve
  these goals, and by standardising practice
  facilitate the audit process.

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Indications for Parenteral Nutrition

• The basic indication for using Parenteral
  Nutrition is a requirement for nutrition when the
  gastrointestinal tract is either not working, not
  available, or not appropriate.

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Indications for Parenteral Nutrition(useful but
not limited)

• Non functioning gut e.g. Paralytic ileus
• Malnourished patients in whom the use of the
  intestine is not anticipated for gt7 days after
  major abdominal surgery.
• Patients with specific conditions severely
  affecting the gastrointestinal tract (such as
  severe mucositis following systemic chemotherapy,
  upper gastrointestinal strictures or fistulae,
  severe acute pancreatitis where jejunal feeding
  is contraindicated).
• In those patients with major resections of the
  small intestine (short bowel syndrome) before
  compensatory adaptation occurs.
• Patients in the Intensive Care Unit (ICU) with
  systemic inflammatory response syndrome (SIRS) or
  multiple organ dysfunction syndrome (MODS).

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Indications for Parenteral Nutrition

• Longer-term PN may be required in a small number
  of patients for various reasons
• Extreme short bowel syndrome of any aetiology.
• Other causes of prolonged intestinal failure
  (atresia, radiation enteritis, some inflammatory
  or motility disorders).

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Starting and Continuing Parenteral Nutrition

• Screeningreferred to the ward dietitian
• Assessment
• EnrolmentPICC or CVC
• Initiation of PNmust be ordered by 11.00am
  daily.
• Early monitoring phasemandatory ward
  observations, and appropriate blood and other
  laboratory tests
• Stable patient phaseless intensive monitoring
• Re-introduction of dietin a graded fashion
• Cessation of PNoral nutritional intake is deemed
  adequate

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Prescribing Parenteral Nutrition

• NitrogenProtein is provided in the form of amino
  acids
• Carbohydrate and Lipidmixture of glucose and
  lipid usually in a ratio of 6040 or 5050
• Volumeall fluid volume requirements including
  losses from wounds, drains, stomas and fistulae
  etc.
• Electrolytesclinical requirements and particular
  extrarenal losses
• Vitamins, Minerals and Trace Elementsroutinely
  on a daily basis,as Zinc or Selenium
• Other medicationsNo drug additions will routinely

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Nursing Care of Patients on PN

• Daily weight (before starting PN and daily
  thereafter)
• 4-6 hourly temperature and blood
  pressure,clinical evidence of infection, general
  well being, etc
• Accurate fluid balance chart and summary
• Capillary glucose monitoring 6 hourly for first
  24 hours
• Daily assessment for CVC/PICC site infection or
  leakage
• Twice weekly 24-hour urine collections for
  Nitrogen balance and electrolytes.
• Bags that have been refrigerated should be
  removed at least 1-2 hours before being hung and
  infused, to allow the solution to reach room
  temperature.

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Stopping Parenteral Nutrition

• Whenenteral or oral nutritional intake is deemed
  adequate or other reasons such as acute
  operations, major metabolic disorders or problems
  with equipment
• HowIf PN needs to stop suddenly or unexpectedly
  an infusion of 5GS should be initiated at
  100ml/h for 5h
• Line removalPICC or CVC may be removed at ward
  level by nursing staff with the appropriate
  training

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ESPEN guidelines on PEG

• 1980,Gauderer and Ponsky first report a
  percutaneous endoscopic gastrostomy (PEG)
• Placement of a PEG/PEJ (percutaneous endoscopic
  jejunostomy) tube is simple, safe and
  well-tolerated by patients
• Modern PEG tube systems made of polyurethane or
  silicone rubber are easy to insert and
  well-tolerated
• PEG-feeding has rapidly spread to become routine
  practice worldwide and is currently the method of
  choice for medium- and long- term enteral feeding?

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Decision tree for the selection of the
appropriatetube system for enteral nutrition
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Indications

• Oncological disorders (stenosing tumours in the
  ear, nose and throat region or the upper
  gastrointestinal tract)
• Neurological disorders (dysphagic states after
  cerebrovascular stroke or craniocerebral trauma,
  cerebral tumours, bulbar paralysis, Parkinsons
  disease, amyotrophic, lateral sclerosis, cerebral
  palsy)
• Other clinical conditions (wasting in AIDS, short
  bowel syndrome, reconstructive facial surgery,
  prolonged coma, polytrauma, Crohn disease, cystic
  fibrosis, chronic renal failure,
  tracheo-oesophageal fistula,etc)

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Indications

• palliative drainage of gastric juices and
  secretions in the small intestine in the presence
  of a chronic gastrointestinal stenosis or ileus.
• Aggressive cancer treatment (chemotherapy,
  radiotherapy) definitely requires an adequate
  individual nutritional strategy.

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Contraindications

• Serious coagulation disorders
• Interposed organs (e.g. liver, colon)
• Marked peritoneal carcinomatosis
• Severe ascites, peritonitis
• Anorexia nervosa, severe psychosis
• Clearly limited life expectancy

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Preparations and aftercare prior to and after
endoscopic placement of an enteral tube system.
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Complications

• The rate of complications after endoscopic
  placement of enteral feeding tubes is estimated
  in the available literature to be in the range
  830
• The most frequent complication is the occurrence
  of local wound infection (in approximately 15 of
  cases)
• pneumoperitoneum after PEG may occur in more than
  50,but not regarded as a complication since
  there is no clinical evidence of adverse
  consequences

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• peristomal abdominal pain, fever (in some
  instances with transient leukocytosis) or
  occasionally transient leakage of the stomach
  contents from the granulating puncture canal
• possible long-term complications after PEG
  include occlusion of the tube, tube porosity and
  fracture with subsequent leakage from the tube or
  the tube connection, development of cellulitis,
  eczema or hypergranulation tissue (proud flesh).