Transcript SUPPLEMENTAL NUTRITION - AMT | Tube Feeding | G-Tube

PROS, CONS, AND CHALLENGES
Sue Kane, SA-C, Clinical Coordinator
Applied Medical Technology, Inc.
Malnutrition
As a general rule, enteral or parenteral feeding is advised
when a patient is unable to eat for 7-14 days or longer.
Malnutrition is a common problem increasing morbidity
and mortality of hospitalized patients and is often not
recognized throughout the hospital stay. This may affect
recovery from illness, surgery and trauma and can result
in poor post operative results as well as wound healing
and post operative complications.
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Protein Malnutrition
Usually caused by inadequate nutrient intake in
conjunction with a stress response
Causes:
Chronic diarrhea, renal dysfunction, infection, hemorrhage,
trauma, burns, critical illness
Results:
Marked hypoalbuminemia, anemia, edema, muscle atrophy,
delayed wound healing, impaired immunocompetence
Protein-Calorie Malnutrition
Typically in the emaciated, elderly and chronically ill patient
Results:
Weight loss, reduced basal metabolism, depletion of subcutaneous
fat and tissue turgor, bradycardia, hypothermia
Risk Factors of Malnutrition
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Recent surgery or trauma
Sepsis
Chronic illness
Anorexia/eating disorders
Dysphagia
Recurrent nausea, vomiting or diarrhea
Pancreatitis
Inflammatory bowel disease
Gastrointestinal fistulas
Consequences of Malnutrition
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Longer recovery time
Impaired defenses and sepsis
Impaired wound healing
Anemia
Impaired G.I tract function
Muscle atrophy
Impaired cardiac function
Impaired renal function
Impaired respiratory function
Brain dysfunction
Atrophic skin
Benefits of early nutrition
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Less time on mechanical ventilation
Reduce infections
Better wound healing
Shorter hospital stays
Maintaining bowel mucosa integrity
May support normal immune function
Decrease translocation of gut bacteria
OVERVIEW
The gastrointestinal (GI) tract is the route by which the body is supplied with
water, electrolytes, and nutrients
There are many clinical conditions in which the GI tract is temporarily or
permanently unavailable, not functioning, or damaged. In these situations,
the patient’s health is seriously jeopardized. Accessing the GI tract can be
done intravenously or by tube feeding. Tubes; nasogastric (NG), nasojejunal
(NJ), gastrostomy (G-tube), jejunal (J-tube), and gastrojejunal (GJ-tube) are
used to provide the body with nutrition, perform gastric decompression, and
to evaluate/treat GI bleeding. Each of these tubes has a specific insertion
technique, specific advantages and disadvantages, and complications. This
presentation will provide a basic review of the anatomy and function of the
GI tract and discuss the use of gastric tubes for enteral nutrition. Specific
radiologic techniques that are used for insertion will be discussed and
described.
Review of G.I. Tract
 The gastrointestinal (GI) tract is involved in
providing the body with water, electrolytes, and
nutrients. In order for this to happen, food must be
transferred through the GI tract, there must be a
secretion of digestive juices, there must be
absorption of water, electrolytes, and nutrients,
and each part of the GI tract is designed to carry
out one of those functions.
SUPPLEMENTAL NUTRITION
 Oral – preferred method
 Intravenously (Parenteral) used primarily for non
functioning GI tract
 Via tube (Enteral) Preferred because it facilitates
maintenance of intestinal structure and function,
improves immunity, and avoids catheter related
complications associated with parenteral nutrition.
Accepted to be safer, associated with better patient
outcomes and more economical than parenteral.
 nasal
 enterostomy
Gastrointestinal Access
 Nutrition
 Gastric Decompression
 Evaluating/Treating patients
with gastrointestinal bleeding
Parenteral
vs.
Enteral
 Nasogastric - Nose to fundus of
 Catheter placed in
vein in arm or chest
 Hickman catheter,
Broviac, PICC line,
single, double or
triple lumen
catheters
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stomach. A catheter tip syringe or
suction tube attaches.
Nasoduodenal/Nasojejunal-Nose to
3rd portion of the duodenum or the
Ligament of Treitz in the jejunum.
Gastrostomy - Abdominal wall to the
stomach.
Gastrojejunostomy - Abdominal wall
to the stomach and the tube is
advanced into the jejunum. Has 3
ports, 1 for the balloon, 1 for the
gastric fluids to be removed, and 1
for nutrition and medicines to be
administered directly into the
jejunum.
Jejunostomy - Abdominal wall to the
jejunum.
*In the setting of a functional gut, enteral feeding is preferred to parenteral options.
Parenteral - PPN (Peripheral)/TPN (Central)
Advantages
 Needed when GI tract is non –
functioning
 Non patent G.I. Tract prior to
surgery
 Post gastrointestinal surgery
 Short Gut Syndrome - A
condition in which the bowel is
not as long as normal, either
because of surgery or because of a
congenital defect. Because the
bowel has less surface area to
absorb nutrients, it can result in
malabsorption syndrome
Disadvantages/Complications
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Catheter associated infections
Air Embolism
Circulatory overload
Hyperglycemia
Hypoglycemia
Catheter Occlusion
Pneumothorax (central line)
Venous thrombosis
Infection
Fluid and electrolyte
complications
Enteral -Nasogastric Indications
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Intact gag reflex
No esophageal reflux
Normal gastric emptying
Stomach uninvolved with primary disease
Contraindications
• NG tube feeding is inadvisable in patients with basilar
skull fractures, severe facial fractures especially to the
nose and obstructed esophagus, esophageal varices, and/or
obstructed airway.
• Intestinal obstruction
• Gastric bypass surgery
Nasogastric feeding tubes NG
Advantages
 Nutrition
 Avoid general anesthesia
 Avoid surgical procedure
 Low incidence of complications
 Reduce abdominal distention
 Speeding up the return of bowel function.
 Decrease the chance of wound dehiscence and hernia post op
 Decrease the chance of wound separation and infection post op
 Easy tube insertion
 Larger reservoir capacity in stomach
Disadvantages and complications
• Highest risk of aspiration
• Abdominal distention
• X-Ray or fluroscopy for
confirmation of tube
placement
• Suited only to short term
(6 weeks)
• Esophageal perforation
• Intracranial placement of
the tube – patients with
severe head trauma,
maxillofacial injury
• Pneumothorax
• Diarrhea
• Fluid and electrolyte
imbalances
• Hyperglycemia
• Nose bleed
• Sinusitis
• Tube migration
• Block easily
• Patient self conscious of
tube
Methods of checking tube
placement
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Air insufflation and auscultation of the epigastrium
Aspiration of gastric contents
pH testing
X-ray confirmation (most reliable way to determine position
of tube)
*Tube should be marked with permanent ink at the point of entry after x-ray confirmation
Nasojejunal tubes
Many clinicians believe that enteral nutrition delivered to the
small bowel is a better choice than feedings delivered to the
stomach, and will place a NJ feeding tube. This type of feeding
tube is more difficult to place than a NG tube, but its proponent’s
say that it decreases the risk of aspiration, may provide more
calories, and the feeding schedule will be subject to fewer
interruptions. Both the jejunum and the stomach can be safely
used to deliver calories, the differences between the two types of
tubes are minimal, both can be effective, and the decision as to
which one to use depends on the skill of the practitioner and the
potential tolerance of the patient.
The NJ tube can be placed using an endoscope or by
using fluoroscopy. When choosing fluoroscopy the
practitioner must weigh the exposure to radiation, the need for
transport to the radiology department, patient safety, and cost.
Some practitioners have reported success by placing the NJ
tube in the stomach and allowing it to spontaneously move
into the small bowel. Magnetically guided tubes have also
been used as well such as the Cortrak System.
Nasoduodenal/Nasojejunal
Indications
• Gastroparesis or
impaired gastric
emptying
• Esophageal reflux
Nasoduodenal/Nasojejunal
Advantages
• Reduced aspiration risk
compared to NG
• Nutrition
• Avoid general anesthesia
• Avoid surgical procedure
• Low incidence of
complications
• Reduce abdominal
distention
• Speeding up the return of
bowel function.
• Decrease the chance of
wound dehiscence and
hernia post op
• Decrease the chance of
wound separation and
infection post op
Disadvantages
• Potential GI intolerance
(bloating, cramping, diarrhea)
• May require endoscopic
placement of nasoenteric tube
• Patient self conscious due to
appearance of tube
• Tube displacement and potential
aspiration
• X-Ray or fluroscopy for
confirmation of tube placement
• Suited only to short term (6
weeks)
• Esophageal perforation
• Intracranial placement of the
tube – patients with severe head
trauma, maxillofacial injury
• Pneumothorax
• Nose bleed
• Sinusitis
It is important to secure feeding tubes.
The incidence of accidental loss is high particularly in the
critically ill who often have altered levels of consciousness.
Nutritional support improves
clinical outcomes.
Frequent tube dislodgement may prevent effective
enteral feeding.
In a prospective study, 21 patients received NG feeding
over 173 days. Only 46% of volume feed prescribed was
delivered. Each patient required between 2-11 tubes and
85.9% dislodgements were due to patient removal.
Less than half of EN patients achieve their caloric goal
*Prospective audit Leeds Teaching Hospitals NHS Trust/Faculty of Health,Leeds Metropolitan University,
Leeds, UK Nov. 2008
Securing Nasal Feeding Tubes
• Tape – Inexpensive
OPTIONS
Disadvantages: Skin breakdown, uncomfortable, risk of nasal injury
• Suturing – Inexpensive, more effective than tape
Disadvantages: Uncomfortable, potential damage to nasal septum
if pulled by patient or clinician
• Bridling (old school) – Effective, inexpensive
Disadvantages: Uncomfortable to place, difficult to place, securing
tube is challenging
• Bridling (AMT Bridle) – Easy to use, safe,
comfortable, cost effective, FDA approved device
An Old Method
A red rubber catheter, usually
an 8fr, was placed through the
nares on each side, retrieved in
the nasopharynx with forceps,
tied together, advanced, and
then tied around the NG tube.
A New Method
The AMT Bridle is an umbilical
tape system placed with magnets
that attract in the nasopharyx to
deliver the umbilical tape
through the nares. The NG tube
is then secure with the umbilical
tape in an appropriate size clip.
Clinical References Regarding Bridling of
Feeding Tubes
“Routine Bridling of Nasojejunal tubes is a safe and effective method
of reducing dislodgement in the ICU. This simple practice can be
performed with low morbidity and may improve enteral nutrition
and reduce exposure to procedural complications.”
Christopher W. Seder, MD; Randy Janczyk, MD: NCP Nutrition in Clinical Practice 2008-2009; 23 (6) 651-654
“Nasal bridling decreases feeding tube dislodgement and may
increase caloric intake in the surgical intensive care unit: A
randomized, controlled trial.”
Christopher W. Seder, MD; William Stockdale, RN; Linda Hale, RN; Randy J. Janczyk, MD, FACS : Critical Care
Medicine 2010, Vol. 38 No.3
"Use of Nasal Bridle Prevents Accidental Nasoenteral Feeding Tube
Removal.”
Scott R. Gunn, MD, Barbara J. Early, RN; Mazen S. Zenati, MD, MPH, PhD; Juan Ochoa, MD, FACS: JPEN Journal of
Parenteral and Enteral Nutrition 2009; 33(1):50-54
IMPROVE OUTCOMES
DECREASE COSTS
• Optimize caloric intake
• Cost of x-ray or fluoroscopy
• Reduced risk of aspiration
• Reduce radiographic exposure
• Cost of extended length of stay
due to sub-optimal nutrition
• Eliminate skin breakdown due to
adhesives
• Cost of new nasal tube, formula
and supplies
• Delay PEG placement or
conversion to TPN
• Cost of clinicians’ time to replace
nasal tube
• Reduce risks of reinsertion
• Pneumothorax
• Esophageal perforation
• Tracheal / Bronchial injury
Preventing blocked tubes
Routine flushing with warm water can prevent
clogging of feeding tubes.
Acidic products can cause proteins in formula to
coagulate. You may need to flush before and after
administering solutions.
As an alternative, pancreatic enzymes with sodium
bicarbonate may be used. Check with physician.
Gastrostomy
placed laparoscopically, operatively, or percutaneously
Indications
• Swallowing dysfunction and subsequent
impairment of ability to consume oral diet
• Intact gag reflex; no esophageal reflux
• Long term feeding; normal gastric emptying
• Stomach uninvolved with primary disease
• Patients with an inability to ingest adequate
nutrients to meet metabolic demands
Percutaneous Endoscopic Gastrostomy
(PEG)
Push or pull method using an endoscope under
local anesthesia and conscious sedation
It is a safer and more cost effective method than
surgical placed gastrostomies and has a lower
mortality rate
May be replaced with low profile device usually
after 6 weeks
Gastrostomy
Advantages
 May be used immediately or
within hours of placement
 may be used for long-term
support
 may be used in presence of
significant disease of upper GI
tract (esophagus, stomach and
duodenum)
 percutaneously placed tubes
avoid risks of general anesthesia
 laparoscopically placed tubes
allow patient to return home
same day as placed
 Larger reservoir capacity in
stomach
Disadvantages/Complications
 Peritonitis
 Stoma care needed
 Gastric perforation
 Hemorrhage requiring transfusion
 Deep stoma infection
 Septicemia
 Aspiration
 Wound infection
 Peristomal leakage/skin excoriation
 Tube dislodgement
 Potential fistula after tube is
removed
 Surgery needed for surgical
gastrostomies
Jejunostomy
A Jejunostomy tube provides nutritional support with the tube
placed directly through the abdominal wall into the jejunum. It
is particularly useful in patients who are at high risk of
aspiration of feedings delivered to the stomach, patients with
non-functional stomachs, patients with esophageal carcinoma
or chronic pancreatitis, and patients who have had a total
gastrectomy.
Jejunostomy - Indications
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Long term feeding
High risk of aspiration
Esophageal reflux
Inability to access upper GI tract
Gastroparesis or impaired gastric emptying
Gastric dysfunction due to trauma or surgery
Jejunostomy
Advantages
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Reduced risk of aspiration
Placed adjunctly with GI surgery
No surgery needed for percutaneous
endoscopic jejunostomy
PEJ less costly than surgical
jejunostomy
Disadvantages
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Potential GI intolerance
Stoma care needed
Peritonitis
Stoma care needed
Hemorrhage requiring transfusion
Deep stoma infection
Septicemia
Wound infection
Peristomal leakage/skin excoriation
Tube dislodgement
Potential fistula after tube is removed
Tube occlusion with small bore tube
Surgery needed for surgical jejunostomies
Gastrojejunostomy tube
When gastroesophageal reflux is present there is a
high risk of aspiration of gastric secretions and
enteral feeding. In this case a G-J tube is used to
aspirate gastric contents and feed into the
jejunum.
The G-J tube is placed into the stomach and
secured by a balloon. There is an extension of the
tube with holes that is guided into the jejunum for
feeding. There are two ports located on the
outside of the tube.
Pros and Cons of Enteral Feeding Technique
Technique
Description
Pros
Cons
Continuous feedings
Administered continuously
using infusion pump
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Minimize risk of
aspiration from reflux or
high residual volume
Allow controlled feeding
into small bowel
Improves glucose control
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Allows controlled feeding
Reduces time pt is
connected to pump
Benefits pts using oral
nutrition during the day
who need supplemental
nutrition
• Requires staff time for set
up
• May require more vigilance
at night
Provides fast
administration
No infusion pump
required
Allow gastric rest
between feedings
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Cyclic feedings
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Bolus feedings
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Administered less than
24 hours/day using
infusion pump
Often used at night
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Administered by gravity
over 5 minutes via syringe
Preferred by home going
pts receiving tube feeds
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Intermittent gravity drip
Use feed bag via gravity drip
over 20-30 minutes
• Faster than continuous and
cyclic feedings
• Often better tolerated
• No infusion pump
• Allows gastric rest between
feedings
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Requires ongoing
monitoring
May waste formula
More likely to cause
adverse effects
Can be used only to
deliver feeding to
stomach
May require more staff
time for feeding
• Cannot use for delivery in
jejunum
• May require more staff
time for set up and delivery
Conclusion
Using a team approach, it is important to start enteral feeding as
early as possible. Providing early feeding will result in the best
outcome for malnourished and critically ill patients resulting in
shorter hospital stays and improving their overall health. Review
patient goals daily and use recommended interventions to avoid
complications.
Bibliography
1. Christopher W. Seder, MD; William Stockdale, RN; Linda Hale, RN; Randy J. Janczyk, MD, FACS, “Nasal bridling decreases feeding
tube dislodgement and may increase caloric intake in the surgical intensive care unit: A randomized, controlled trial.” Critical Care
Medicine 2010, Vol. 38 No.3
2. Scott R. Gunn, MD, Barbara J. Early, RN; Mazen S. Zenati, MD, MPH, PhD; Juan Ochoa, MD, FACS, "Use of Nasal Bridle Prevents
Accidental Nasoenteral Feeding Tube Removal."JPEN Journal of Parenteral and Enteral Nutrition 33(1):50-54,2009
3. Chris Winkleman, PhD, RN, CCRN, Kathleen Best, RD, LD, CNSD, Formula for success: Deliver enteral nutrition using best
practices, American Nurse Today, 2009
4. Coupe, AM, Donnellan, CF, Copeman, J. ,How effective is enteral nutrition via naso-gastric tubes in patients with alcohol liver
disease?, roceedings of the Nutrition Society, 68 (OCE1), E7, 2009
5. Christopher W. Seder, MD; Randy Janczyk, MD, "The Routine Bridling of Nasojejunal Tubes Is a Safe and Effective Method of
Reducing Dislodgement in the Intensive Care Unit.“, NCP Nutrition in Clinical Practice 2008-2009; 23 (6) 651-654.
6. RX Kinetics, Management of Enteral Nutrition, www.rxkinetics.com/tpntutorial2_2.html, 2008
7. Nirav Thosani, Complications of Total Parenteral Nutrition, www.sci.med.nutrition
8. McClave, S., Critical Care Nutrition: The Importance of Delivering Early Enteral Feeding, American Society for Parenteral and
Enteral Nutrition, 2007
9. Dana Bartlett, RN, MSN, CSPI & J. Werner R.T. (R), , Enteral Feeding Tubes and Gastric Decompression Tubes, adiographic Imaging
CEU Source, 2006
10. Williams, Teresa A., Leslie, Gavin D., A review of the nursing care of enteral feeding tubes in critically ill adults: Part I, ntensive and
Critical Care Nursing 2004
11. Enteral and Parenteral Nutrition Support, University of Wisconson, Green Bay, http://www.uwgb.edu/ laceyk/ NutSci486/
Chapter23.ppt 1.8Mb, 2004
12. James A. DiSario, MD, Wililam N. Baskin, MD, Russel D. Brown, MD, MarkH. DeLegge, MD, John C.Fang, MD, Gregory G
Ginsberg, MD, Stephen A. McClave, MD, Endoscopic approaches to enteral nutritional support, Gastrointestinal Endoscopy, Volume
55, No.7 2002
13. Pearce,C,B., Duncan, H.D., Enteral Feeding. Nasogastric, Nasojejunal, Percutaneous Endoscopic Gastrostomy, or Jejunostomy: Its
Indications and Limitations, Post Graduate Medical Journal 2001
14. Susan Bussell, R.D., Kim Donnelly, R.Ph., Scott Helton, M.D., Susan Kracke, R.Ph., Robert Labbe, Ph.D., Edward Lipkin, M.D.,
Ph.D., Jill McCormick, M.S.,R.D., Patricia Riley, R.D., Megan Veldee, M.S., R.D., Sarah Washburn M.S., R.D.,, A Resource Book for
Delivering Enteral and Parenteral Nutrition for Adults, Clinical Nutrition - University of Washington Academic Medical Centers
http://healthlinks.washington.edu/nutrition/section5.html, 1997