HX2.3 Nurition in the Seriously Ill

Question 1

What is nutritional support?

Answer 1

Nutrition support refers to enteral or parenteral provision of calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids

Question 2

What is the goal of nutrition support?

Answer 2

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

Question 3

How is acute critical illness characterized in nutritional terms?

Answer 3

Characterized by catabolism exceeding anabolism

i.e. Catabolic State

Question 4

What is the preferred nutritional source during acute illness?

Answer 4

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.

Question 5

How is recovery from acute illness characterized in nutritional terms?

Answer 5

Recovery is characterized by anabolism exceeding catabolism

Question 6

What is the role of nutrition during the anabolic state?

Answer 6

Nutrition support provides substrate for the anabolic state, during which the body corrects
Hypo-proteinemia,
Repairs muscle loss,
Replenishes other nutritional stores

Question 7

What is artificial nutrition?

Answer 7

Nutritional support of an invasive nature, requiring the placement of a tube either

Question 8

Broadly speaking, what are the options for tube placement?

Answer 8

1. Directly into the gastrointestinal tract
   Known as enteral nutrition
2. Directly into a vein
   Known as parenteral nutrition

Question 9

What are the types of enteral nutrition?

Answer 9

PEG Tube

NG Feeding

Question 10

What is a PEG tube?

Answer 10

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

Question 11

When is a PEG tube used?

Answer 11

Used when patients unable to maintain adequate nutrition with oral intake.

Question 12

How is a PEG tube inserted?

Answer 12

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.

Question 13

What is a RIG?

Answer 13

Radio-logically Inserted Gastrostomy

A narrow plastic tube is placed through the skin, directly into your stomach, under x- ray guidance

Question 14

What are the advantages of PEG feeding?

Answer 14

 Well tolerated
 Improves nutritional status
 Easy to use
 Cost-effective relative to alternative methods

Question 15

What are the potential immediate complications of PED tube insertion?

Answer 15

ENDOSCOPY RELATED 
Haemorrhage
Perforation
Aspiration
Over-sedation

PROCEDURE RELATED
Ileus
Pneumo-peritoneum
Infection
Bleeding
Injury to liver,bowel,spleen

Question 16

What are the potential delayed complications of PEG feeding?

Answer 16

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

Question 17

What are the potential S/E of PEG feeding? Why?

Answer 17

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.

Question 18

What is the Tx for GI S/E’s of PEG feeding?

Answer 18

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

Question 19

What are the contraindications for use of PEG?

Answer 19

1. Active coagulopathies & thrombocytopenia
2. 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

Question 20

What are the partial contraindications for use of PEG?

Answer 20

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

Question 21

What is NG feeding?

Answer 21

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

Question 22

What are the advantages of Nasal-jejunal tubes?

Answer 22

These reduce the incidence of gastro- oesophageal reflux

Useful in the presence of delayed gastric emptying.

Question 23

What should be check after insertion of a NJ/NG tube?

Answer 23

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.

Question 24

What are the potential complications of NG/NJ tube?

Answer 24

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

Question 25

What is TPN?

Answer 25

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

Question 26

What does TPN solution typically contain?

Answer 26

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

Question 27

What requires close monitoring during TPN?

Answer 27

Weight, U&E,FBC, LFTs, Glucose, fluid balance

Question 28

What are the potential metabolic complications of TPN?

Answer 28

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.)

Question 29

What are the potential procedure related complications of TPN?

Answer 29

Procedure related:
Pneumothorax, haematoma, air embolism
Thromboembolism and line sepsis
Volume overload may occur when high daily energy requirements necessitate large fluid volumes.

Question 30

What do the medical council guidelines say as regards artificial nutrition?

Answer 30

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.

Question 31

On what basis should patients accept/refuse artificial nutrition?

Answer 31

Potential benefits/risks/discomfort of treatment

Religious & cultural beliefs

Question 32

When might AN improve patient survival?

Answer 32

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)

Question 33

What does the evidence say about TPN use in Palliative Care?

Answer 33

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

Question 34

What are the ethical principles regarding treatment of any patient?

Answer 34

 Autonomy
 Beneficence
 Non-maleficence
 Justice

Question 35

What should be considered when deciding to use AN?

Answer 35

 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

Question 36

What are the argues to counter the perception that holding AN is starving the patient

Answer 36

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

Question 37

What is the term given to weakness and wasting of the body due to severe chronic illness?

Answer 37

Cachexia

Question 38

What is the difference between withdrawing and withholding treatment? What principle governs both?

Answer 38

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

Question 39

When is treatment withdrawn in palliative care?

Answer 39

When not improving symptoms or quality of life

Question 40

What is the difference between Ordinary and Extraordinary Means?

Answer 40

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

Question 41

What criteria should be used in deciding what is an appropriate treatment?

Answer 41

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)