Basics of enteral and parenteral
nutrition
Surgical Nutrition Training Module
Level 1
Philippine Society of General Surgeons
Committee on Surgical Training
Objectives
• To discuss the different feeding pathways for
the surgical patients
• To define and discuss key points of enteral and
parenteral nutrition
• To discuss the monitoring process and
expected outcomes for surgical patients
Feeding Pathways
Can the GIT be used?
“Inability to use the GIT”
Yes
No
“inadequate intake”
Parenteral nutrition
Oral
Tube feed
< 75% intake
Short term
Long term
Peripheral PN
Central PN
More than 3-4 weeks
Yes
No
NGT
Gastrostomy
Nasoduodenal
or nasojejunal
Jejunostomy
A.S.P.E.N. Board of Directors. Guidelines
for the use of parenteral and enteral
nutrition in adult and pediatric patients,
III: nutritional assessment – adults. J
Parenter Enteral Nutr 2002; 26 (1 suppl):
9SA-12SA.
EARLY ENTERAL NUTRITION
Early enteral nutrition: definition
• Enteral nutrition that is initiated within
24 – 48 hours following hospitalization,
trauma, or injury
Zaloga GP. Crit Care Med 1999; 27: 259
Why early enteral nutrition?
• The normal and designed route for nutrient
intake, digestion, and absorption
• Immunocompetence is a major function of the
gastrointestinal tract
• Non-utilization of the gastrointestinal tract
even on a short term basis leads to
complications in critical care or geriatric
patient management
• Cost-effective
Early enteral feeding: goal
• To maintain intestinal mucosal integrity
– Normal microvilli
 Height and number
– Normal intestinal barrier
– Intestinal mucosal immunity
Early enteral feeding: rationale
• Provide nutrients required during metabolic
stress
• Maintain GI integrity
• Reduce morbidity compared with parenteral
nutrition
• Reduce cost compared with parenteral
nutrition
Early enteral nutrition vs standard nutritional
support on mortality
Comparison: mortality
Heyland et al. JAMA, 2001
Outcome: early enteral nutrition vs. control
Study
Treatment
n/N
Control
n/N
Cerra et al 1990
1/11
1/9
Gottschlich et al, 1990
2/17
1/14
0/19
1/51
24/163
1/16
0/18
2/47
12/143
1/17
Ross Products, 1996
Engel et al, 1997
20/87
7/18
8/83
5/18
Mendez et al, 1997
1/22
1/21
2/16
2/16
96/197
2/13
4/13
86/193
17/89
28/87
Brown et al, 1994
Moore et al, 1994
Bower et al, 1996
Kudsk et al, 1996
Rodrigo et al, 1997
Weimann et al, 1998
Atkinson et al, 1998
Galban et al, 2000
Pooled Risk Ratio
0.01
0.1
Higher for control
1
10
100
Higher for treatment
ENTERAL NUTRITION
Enteral nutrition access
STOMACH
JEJUNUM
Nasogastric tube
Nasojejunal tube
PEG
PEJ
BUTTON
JET-PEG
PLG
PLJ
Witzel, Stamm,
Janeway
NCJ
PSJ
PSG
PFJ
PFG
E: Endoscopic
G: Gastrostomy
J: Jejunostomy
L: Laparoscopic
NC: Needle Catheter
S: Sonographic
F: Fluoroscopic
Loser C et al. ESPEN guidelines on artificial enteral
nutrition – Percutaneous endoscopic gastrostomy
(PEG)
Access and delivery
Nasogastric tube
Nasoentericor jejunal tube
PEG tube
Gastrostomy
100
90
80
number
70
60
50
40
30
20
10
PEG placement
0
PEG placement,
St Luke’s Medical Center
2000
2001
2002
2003
Post-pyloric feeding
Short Term
Long Term (operative)
Nasoenteric
– Nasoduodenal
– Nasojejunal
Jejunostomy
– Percutaneous endoscopic
jejunostomy or through the
PEG tube
– Surgical jejunostomy
Gauderer MW, et al. J Pediatr Surg 1980;15:872-875
Enteral Formulas – what type?
•
Polymeric formulas (80-90%)
•
•
•
•
•
Commercial (preferred)
Blenderized (If not critically ill, not severely
malnourished)
Oligomeric formulas
Disease-specific formulas
Modular formulas (concentrated protein and
carbohydrate preparations)
Enteral nutrition delivery
Gravity Feeding
Enteral Pump Delivered
Practical points: enteral nutrition
• If intake is within the range of 60% to 70% start oral
supplement
– Choose the product or preparation that meets all the daily
requirements
• If oral intake is 50% or less
– You may give parenteral nutrition to supplement (good for
a week – expensive, but more comfortable for the patient)
– Cost-effective: NGT
• If tube feeding duration will exceed 2 weeks and you
are looking at long term (stroke or critical care) –
gastrostomy is easier to maintain with lesser
complications (aspiration)
Practical points: enteral nutrition
• If patient will undergo surgery and you doubt patient
will be able to have adequate intake for longer term:
– Place gastrostomy during the surgery
• If gastric function return is in doubt for more than a
week:
• Gastrostomy with jejunostomy tube extension
• Surgical Jejunostomy
• Main goal: adequate intake
Enteral formula: commercial vs. blenderized
Commercial Formulas
Blenderized Formulas
Uniform contents
Sterile
Daily nutrient variability
Non-sterile; high bacterial
content and other pathogens
High viscosity
Does not provide adequate
caloric density
Low viscosity
Lactose free
Defined caloric density
Gallagher-Alfred. Nutrition Supp Svc 1983;
Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:268-273
Bacterial contamination in standard
tube feeds
Standard Feed: measured vs. expected
Calories (kcal/100 g)
152
160
140
129
120
100
106.5
88
86.9
80.9
90.2
expected
80
53.6
60
measured
40
Protein (gm/100 g)
20
0
Hosp A
Hosp B
Commercial formula
Hosp C
Hosp D
Natural food formula
6
5.5
5
3.63
4
3.1
3
3
2.83
2.8
1.9
2
expected
2.13
measured
1
0
Hosp A
Hosp B
Commercial formula
Hosp C
Hosp D
Natural food formula
Sullivan MM et al. Nutritional analysis of blenderized diets in the Philippines (PENSA 1998)
Monitoring Gastric Residuals
•
•
Monitor according to hospital protocol (e.g., every 3-4
hours)
Volume not to exceed 50% of the amount infused
Mentec H, et al. Crit Care Med 2001;29:1955-1961
PARENTERAL NUTRITION
Parenteral nutrition: Indications
• To avoid periods of starvation within 24 to 72 hours
when oral or enteral intake are insufficient to achieve
adequate intake in moderate to severe
malnourished patients
• When unable to use the gut
–
–
–
–
Gut obstruction
Short bowel (intestinal failure)
High output enterocutaneous fistulae
Non-functional gastrointestinal tract
ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009; 28(4): 359-479.
Contraindications to PN
• Gut can be used:
– Ability to consume and absorb adequate nutrients
orally or by enteral tube feeding
– Hemodynamic instability
– *Ineffective and probably harmful in non-aphagic
oncological patients in whom there is no
gastrointestinal reason for intestinal failure.
.* Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral
Nutrition: Non-surgical oncology. Clin Nutr 2009; 28(4): 448.
Types of parenteral nutrition
Central
•
•
•
•
•
•
•
Amino acids ( > 5%)
Dextrose ( > 20%)
Lipids
Includes vitamins, minerals,
and trace elements
Carrier of pharmaconutrients
like glutamine or omega-3fatty acids
Osmolality ( > 700 mOsm/kg
H2O)
Volume restriction
Peripheral
•
•
•
•
Total kcal limited by
concentration and ratio to
volume being administered
(usually delivers between
1000 to 1500 kcal/day)
The current formulations can
now deliver the daily
requirements of macro and
micronutrients
Osmolality < 700 mOsm/kg
No volume restriction
Types of parenteral nutrition
• Central parenteral
nutrition
• Peripheral central
parenteral nutrition
PICC =peripherally inserted
central catheter
Catheters
Subclavian catheter (3 ports)
PICC line catheters
Types of parenteral nutrition
• Peripheral
parenteral
nutrition
Central venous access
• Allows delivery of nutrients into the superior vena
cava or right atrium
• Osmolarity - traditional cut off > 860 mOsm/L
• Catheter differences :
– According to duration of use
– Various lengths, gauges, and number of ports
– Catheters treated with antibacterials
• Nutrient infusion via a dedicated catheter lumen
•
Pittiruti M et al. ESPEN Guidelines on Parenteral Nutrition: Central
Venous Catheters. Clin Nutr 2009; 28(4): 365-7.
Formulations
•
1 Optimal
nitrogen sparing is shown to be achieved
when all components of the parenteral nutrition mix
are administered simultaneously over 24 hours.
• The different forms of PN packaging and delivery:
– 2 Individualized
– 2 Compounded
– 1,2 “All in One”
1. Braga M et al. ESPEN Guidelines on parenteral nutrition. Clin Nutr 2009; 28(4): 382.
2. Kumpf VG et al, ASPEN Nutrition Support Practice Manual 2nd ed 2005; 97-107.
Formulation / Delivery
Development
phases of the PN
container system
Individualized
delivery system
Compounding / clean
rooms
Break seal
“All in one” placed in
multi-chambered bags
• cheaper
• stable
• none to minimum
contamination
Safety issues
Protocols:
1. Compounding
2. Incorporation – additives
3. Delivery (access, rates of
infusion, infusion pumps)
Three in one bags:
longer storage
and less
contamination
In-lineFilters:
1. Fat emulsions
2. Three in one
solutions
3. Microprecipitates
EN/PN monitoring parameters
Metabolic
Assessment
•
•
•
•
•
•
•
Glucose
Fluid and electrolyte
balance
Renal and hepatic function
Triglycerides and
cholesterol
•
•
•
Nutrient balance (calorie &
protein intake)
Body weight
Nitrogen balance
Plasma protein (albumin,
pre-albumin)
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics.
Yale University Press, 1992
Ch 17: parenteral nutrition. Total Nutrition Therapy ver. 2, 2003; 311-12.
Key monitoring points
• Fluid balance – avoid fluid accumulation
within 4-5 days post op
• Calorie balance
• Gastric retention for enteral nutrition
• Blood tests:
– BUN high – dialyze
– High triglycerides – lower lipid flow
– Hyperglycemia – insulin
• Weight once a week
Jan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003
OUTCOME IS DEPENDENT ON THE
MONITORING PROCESS
Feeding Pathways
Can the GIT be used?
“Inability to use the GIT”
Yes
No
“inadequate intake”
Parenteral nutrition
Oral
Tube feed
< 75% intake
Short term
Long term
Peripheral PN
Central PN
More than 3-4 weeks
Yes
No
NGT
Gastrostomy
Nasoduodenal
or nasojejunal
Jejunostomy
A.S.P.E.N. Board of Directors. Guidelines
for the use of parenteral and enteral
nutrition in adult and pediatric patients,
III: nutritional assessment – adults. J
Parenter Enteral Nutr 2002; 26 (1 suppl):
9SA-12SA.
Calorie,
protein,
fluid
balance
form
Nutrient
monitor
form
Monitoring
DOCUMENTED OUTCOMES
Adequate intake in surgery patients
Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate
energy and protein intake on morbidity and mortality in surgical patients
nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s
Nutrition team and intake
Llido et al. Nutrition team supervision improves intake of critical care
patients in a private tertiary care hospital in the Philippines: report from
years 2000 to 2011 (for submission)
THANK YOU