HX2.3 Nurition in the Seriously Ill Flashcards
What is nutritional support?
Nutrition support refers to enteral or parenteral provision of calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids
What is the goal of nutrition support?
The primary goal is to supply the substrate necessary to meet the metabolic needs of patients in whom adequate nourishment cannot be provided by oral intake
How is acute critical illness characterized in nutritional terms?
Characterized by catabolism exceeding anabolism
i.e. Catabolic State
What is the preferred nutritional source during acute illness?
Carbohydrates are the preferred energy source during this period because fat mobilization is impaired
Nutrition support supplies the nutrients necessary to meet the demands of the catabolic state.
How is recovery from acute illness characterized in nutritional terms?
Recovery is characterized by anabolism exceeding catabolism
What is the role of nutrition during the anabolic state?
Nutrition support provides substrate for the anabolic state, during which the body corrects
Hypo-proteinemia,
Repairs muscle loss,
Replenishes other nutritional stores
What is artificial nutrition?
Nutritional support of an invasive nature, requiring the placement of a tube either
Broadly speaking, what are the options for tube placement?
- Directly into the gastrointestinal tract
Known as enteral nutrition - Directly into a vein
Known as parenteral nutrition
What are the types of enteral nutrition?
PEG Tube
NG Feeding
What is a PEG tube?
Percutaneous Endoscopic Gastrostomy
A PEG provides nutrition support directly into the stomach
Difficulties with oral intake
-Oro-pharyngeal & oesophageal malignancy
Neurologically Unsafe Swallowing
- Chronic progressive neuromuscular disease. e.g. MND
- 14 days post acute stroke, where swallow has not recovered
Other Head injury Crohn’s Disease Fistulae (+Other causes of short bowel syndrome) Severe burns Cystic fibrosis
When is a PEG tube used?
Used when patients unable to maintain adequate nutrition with oral intake.
How is a PEG tube inserted?
Endoscope is placed in the mouth, through the oesophagus & into the stomach.
Ensures correct positioning of the PEG tube in the stomach.
PEG tube rests in the stomach and exits through the skin of the abdomen.
What is a RIG?
Radio-logically Inserted Gastrostomy
A narrow plastic tube is placed through the skin, directly into your stomach, under x- ray guidance
What are the advantages of PEG feeding?
Well tolerated
Improves nutritional status
Easy to use
Cost-effective relative to alternative methods
What are the potential immediate complications of PED tube insertion?
ENDOSCOPY RELATED Haemorrhage Perforation Aspiration Over-sedation
PROCEDURE RELATED Ileus Pneumo-peritoneum Infection Bleeding Injury to liver,bowel,spleen
What are the potential delayed complications of PEG feeding?
Gastric outlet obstruction Buried bumper syndrome Dislodged peg tube Peritonitis Periostomal leakage or infection Skin/gastric ulceration Blocked peg tube Tube degradation Gastric fistula after peg tube removal Granulation around site of insertion of peg tube
What are the potential S/E of PEG feeding? Why?
Enteral feeding can result in gastrointestinal symptoms such as abdominal bloating, cramps, nausea, diarrhoea, & constipation.
Gut motility & absorption are promoted by hormones released during mastication. Mastication does not occur in PEG feeding/
Reflux
Reflux occurs frequently especially in:
Patients with impaired consciousness, Poor gag reflex, When fed in the supine position.
What is the Tx for GI S/E’s of PEG feeding?
Reduced slower infusion rates,
Continuous rather than bolus feeding
Alternative feed preparation
Addition of pro-kinetic agents
Reflux
Patients should…
Be propped up by at least 30° whilst feeding
Remain in that position for a further 30 minutes
What are the contraindications for use of PEG?
- Active coagulopathies & thrombocytopenia
- Anything that precludes endoscopy (Haemodynamic compromise, sepsis or a perforated viscus)
3. Other Acute severe illness, Anorexia, Previous gastric surgery, Peritonitis, Ascites, Gastric outlet obstruction
What are the partial contraindications for use of PEG?
Infection: active systemic infection increases the risk of early mortality & morbidity post-PEG placement.
Other comorbidities:
Diabetes mellitus,
COPD
Low albumin levels.
Ventriculo-Peritoneal Shunts (CSF)
Severe Kyphoscoliosis
What is NG feeding?
Short-term access is usually achieved using nasogastric (NG) or naso-jejunal (NJ) tubes
Allows the use of hypertonic feeds, high feeding rates & bolus feeding into the stomach
What are the advantages of Nasal-jejunal tubes?
These reduce the incidence of gastro- oesophageal reflux
Useful in the presence of delayed gastric emptying.
What should be check after insertion of a NJ/NG tube?
CxR to confirm placement.
CHECKLIST
Tube follows straight course down midline to point below diaphragm
Does not follow the path of a bronchus
Tube is not coiled anywhere in the chest
The tip of the tube is below the diaphragm.
What are the potential complications of NG/NJ tube?
Nasopharyngeal discomfort
Later nasal erosions, abscesses & sinusitis
Acute complications
Pharyngeal or oesophageal perforation, intracranial or
bronchial insertion are uncommon, they may be fatal.
Longer use
May cause oesophagitis, oesophageal ulceration & stricture
What is TPN?
Total Parenteral Nutrition
A way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein
What does TPN solution typically contain?
Solution contains amino acids, glucose, fat,
electrolytes, trace elements, & vitamins.
Vitamin B12 given by IM injection (only repeated if on TPN long term).
Folic acid given once/twice a week in the solution
Other vitamins usually given daily
What requires close monitoring during TPN?
Weight, U&E,FBC, LFTs, Glucose, fluid balance
What are the potential metabolic complications of TPN?
Hyperglycaemia,
Hyperosmolality,
Elevation of urea,
Abnormalities of serum electrolytes, minerals & vitamin deficiencies (Metabolic bone disease in some patients receiving long-term TPN is associated with low serum calcitriol.)
What are the potential procedure related complications of TPN?
Procedure related:
Pneumothorax, haematoma, air embolism
Thromboembolism and line sepsis
Volume overload may occur when high daily energy requirements necessitate large fluid volumes.
What do the medical council guidelines say as regards artificial nutrition?
There is no obligation on you to start or continue a treatment, or artificial nutrition and hydration, that is futile or disproportionately burdensome, even if such treatment may prolong life.
On what basis should patients accept/refuse artificial nutrition?
Potential benefits/risks/discomfort of treatment
Religious & cultural beliefs
When might AN improve patient survival?
AN may improve survival in…
Patients with permanent vegetative state
Patients with extreme short bowel syndrome (parenteral)
Patients with bulbar MND
Acute phase of a stroke or head injury & in patients receiving short term critical care
The nutritional status of patients with advanced cancer undergoing intensive radiotherapy
Controversial in chemotherapy (most evidence suggests no benefit)
What does the evidence say about TPN use in Palliative Care?
Evidence supporting use of TPN in advanced cancer remains controversial
Occasionally weight loss in advanced cancer may be due to malnutrition
In 2009, a Cochrane review:
Lack of methodologically rigorous studies precluded any clinical recommendations with respect to the use of medically assisted nutrition
There are limited anecdotal reports that patients with good performance status & medium to long term prognoses may benefit from TPN
What are the ethical principles regarding treatment of any patient?
Autonomy
Beneficence
Non-maleficence
Justice
What should be considered when deciding to use AN?
Patient’s wishes (autonomy)
Risks (non-maleficence)
Potential benefits (beneficence)
Decisions about the use of artificial nutrition should be made in the same way as other decisions of medical treatment
What are the argues to counter the perception that holding AN is starving the patient
Artificial nutrition is not a basic intervention
Has more in common with other surgical/medical interventions that require technical expertise than with simple feeding
Uncertain benefits, considerable risks & potential discomfort
If physician has belief that significantly differs from patient/family then consider seeking a 2nd opinion or transferring care
What is the term given to weakness and wasting of the body due to severe chronic illness?
Cachexia
What is the difference between withdrawing and withholding treatment? What principle governs both?
Withholding a treatment =a treatment is available but is not given
Withdrawing a treatment = a treatment is started but then stopped because it is not working
Little philosophical distinction
Decision to withhold or withdraw treatment is guided by the principle of non-maleficence
When is treatment withdrawn in palliative care?
When not improving symptoms or quality of life
What is the difference between Ordinary and Extraordinary Means?
Ordinary means
All medicines & treatments which offer a reasonable hope of benefit for the patient & which can be obtained without imposing excessive burdens
Extraordinary means
Treatments which cannot be obtained without excessive inconvenience to the patient or do not offer a reasonable hope of benefit
What criteria should be used in deciding what is an appropriate treatment?
What is the therapeutic aim of the treatment?
What is the patient’s disease, how severe is it & what is the prognosis?
What are the potential adverse effects of the treatment?
Can be started on a trial basis, if no improvement then stop..(important that patient/family are aware of this plan)
