Breiga Pepping Clinical Dietitian Dunedin Hospital

Malnutrition State of nutrition in which a deficiency/excess (or

imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body forms or function and clinical outcomes

Protein Energy Malnutrition:• BMI <18.5 or weight loss of at least 5% in 6/12 (AND)

• evidence of suboptimal intake which has resulted in subcutaneous fat loss and/or muscle wasting

Malnutrition and overweight /obesity can co-exist

Regularly under-diagnosed and under-treated

Implications of Malnutrition Reduced ability to fight infection

Inactivity and reduced ability to work, shop, cook, self care • inactivity can lead to pressure ulcers and blood clots

Falls

Reduced QOL

Impaired mental health- depression, introversion, self-neglect

Impaired wound healing

Impaired treatment tolerance i.e. cancer treatments

Financial:

LOS, hospital admissions/readmissions, health care costs

Treatment interruptions

Artificial Nutrition Support Provision of nutrition support to meet nutritional

requirements in patients with inadequate oral intake

• sole source of nutrition

• supplementary nutrition

TPN/Enteral

• enteral feeding usually the most preferred method

• combination

Indications Severe malnutrition

• weight loss >10%, muscle wasting, peripheral oedema

Moderately malnourished but would be expected to develop significant malnutrition due to underlying disease

Well nourished but unable to commence normal feeding for considerable length of time (>3-4d)

Unable to meet nutritional needs with oral intake alone

Unable to eat/drink safely i.e. dysphagia

Contraindications for Enteral

Nutrition Major intra-abdominal sepsis

Total obstruction of gastrointestinal tract or

abdominal distension of unknown pathology

Malabsorption i.e. short bowel syndrome,

severe and intractable diarrhoea

Benefits of Enteral Nutrition

• Lower cost compared with TPN

• Enteral feeding shown can decrease risk of

bacterial translocation and therefore

bacteraemia

Goals of Enteral Nutrition• Achieve optimal nutritional status / hydration

• Correct significant nutritional deficiencies

• Achieve a satisfactory body weight

• Achieve normal metabolic parameters and fluid balance i.e. albumin, urea, creatinine, electrolytes, Hb.

• Allow for normal bowel function

• Facilitate the transition to oral intake when the clinical condition allows

• Reflect the wishes of the patient +/- their family

Enteral Nutrition Types of enteral nutrition:

NGT/ NJT/ PEG/ PEJ/ RIG

Stomach (NGT/PEG/RIG) preferable option

can do both bolus and continuous feeding

Small bowel continuous feeding only

NGT/NJT vs PEG/PEJ/RIG length of time enteral support required

patients condition

Other considerations

Possible Reasons for PEG • Neurological Diseases:

• Cerebrovascular

disease/stroke

• Motor Neuron disease

• Dementia

• Cerebral Palsy

• Multiple sclerosis

• Cancer

• Head and Neck / Oesophageal

• Burns

• Cystic Fibrosis

• Liver Disease

• Short bowel syndrome

• Chronic renal failure

• Head Injury

Contraindications for PEG Serious coagulation disorders

Hemodynamic instability

Sepsis

Sever Ascites

Peritonitis

History of total gastrectomy

Gastric outlet obstruction (if for feeding)

Sever gastroparesis (if for feeding

Interposed organs i.e. liver, colon

Marked peritonitis, anorexia nervosa

Limited life expectancy

Nutritional Assessment Anthropometry

height & weight

Biochemistry

Fluid & nutritional requirements

Food & fluid intake

Medications & interactions

Clinical condition CVA, cancer etc.

Social situation

Feeding Considerations

Aim of enteral nutrition support

sole source of nutrition vs supplementary nutrition

weight maintenance/gain/loss

Formula type and amount

Feed administration

Aspiration Risk

Flushes: how many and when

hydration / keep enteral feeding tubes clean and patient

Other Considerations: Refeeding Syndrome

Potentially fatal

Sever electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding

At risk if severely malnourished or very little or no food for more than 5 days

Common features sever fluid and electrolyte shifts → ↓P04, ↓K+, ↓Mg,

glucose abnormalities and thiamine and trace-element deficiencies

Other Considerations: Refeeding Syndrome

Identify patients at risk before starting enteral nutrition

Baseline electrolyte level + ongoing monitoring until the patient is metabolically stable

Feeding needs to be started cautiously

Serum levels do not need to corrected prior to commencing nutrition support- can be corrected during nutrition support

Medications Water flushes before and after is very important to

prevent blockages

Need to consider interactions with food, vitamins, electrolytes

medications that need to be given on an empty stomach

osmolality

sorbitol content

Medications: Commonly Used in Enteral Feeding

Anti Nausea / Motility agents: Metoclopramide Ondansetron Erythromycin

Laxatives Coloxyl with Senna Laxsol Lactulose Movicol

Antidiarrhoeals Loperamide Codeine Phosphate

Formulas Nutritionally complete

Lactose and gluten free

Range from 1-2kcal/ml

With or without fibre

Ready to hang

Closed system

1000ml or 500ml packs

Shelf life 24hrs after opening

12hrs if decanting

Formulas

Polymeric (whole protein)

protein in the form it is normally within the diet

Pre-digested (peptide/semi-elemental/elemental)

protein as smaller molecules i.e.; short peptides or free

amino acids

malabsorption / allergies

Disease Specific

diabetes / renal / fluid restriction /

Administration of Formula Bolus feeding

PEG / NGT only

Gravity / Syringe Push / Pump Bolus

usually over 5-6 feeds spread out over the day

Continuous feeding gastric and small bowel

via pump

feed continuously up to 24hrs a day

Combination bolus + continuous feeding

Administration of Formula Considerations: inpatient

patients clinical condition

rehab vs acute setting

staffing

treatments/procedures

Considerations: Discharge Planning rest home/hospital level care vs Home

supports available

patients ability and wishes aim to reduce impact of enteral feeding on QOL

Monitoring Gastric Residuals

when initiating NGT/PEG feeding

every 4hrs until feeding has reached goal rate

can only check if feeding into the stomach

Vomiting / Nausea anti nausea medication

rate/amount/type of feed

residuals

Monitoring Abdominal distension, cramping

temperature of feed

speed bolus feeds administered

gastric residuals

constipation

Monitoring Diarrhoea

medications e.g., sorbitol, magnesium, antibiotics

infection i.e. C Diff

resolving ileus

type of feed- osmolality/fibre

use of anti-diarrhoeal agents

Usual bowel habit

Temperature of feed

Administration rate of bolus feeds

Constipation fibre

fluid

medications- pain medications

decreased mobility

Monitoring Biochemistry

K, Ca, PO4, Mg- refeeding

urea, creatinine, Na, Albumin / CRP

liver function- detect overfeeding

vitamin D

Dietary intake compare intake with requirements and enteral intake

facilitate weaning from enteral to oral intake

food charts / diet history

Monitoring Fluid balance

important in heart, renal, liver patients where fluid restrictions may be needed

input and output

daily in acute setting- fluid balance charts

compare feed/fluid volume given with feed prescribed

Weight assess changes on hydration and body composition over time under/over feeding fluid shifts / changes in hydration weekly/twice weekly when starting or if hydration concerns monthly for an established home enteral feed

Monitoring

Clinical condition of patient

ensure feed tolerated

feeding route remain appropriate

changes in treatments

changes in lifestyle

Enteral to Oral Intake

50% of calorie requirements orally + 2 x high protein supplements

SLT

Food charts really important in assessing oral intake

Overnight feeding

Intermittent bolus feeding with oral intake

References Percutaneous endoscopic gastrostomy: indications,

technique, complications and management (World

Jrnl Gastroenterology: 2014 Jun 28:20(24)

ESPEN guidelines of artificial enteral nutrition-PEG:

Clinical Nutrition 2005

BAPEN Website

Guide to Refeeding Syndrome- Southern District

Health Board