Clinical Nutrition 3

1. Clinical Nutrition 3  Enteral Nutrition

2. Indications for Enteral Nutrition The patient • is not able to eat to eat • is not allowed to eat • refuses

3. Indications of Enteral Nutrition • mechanical obstructions • inadequate food-intake • maldigestion / malabsorption Indications • inflammatory processes • neurogenic disorders • trauma / sepsis • drug / radiation therapy • chronic diseases • preoperative and postoperative conditions

4. Indication: Maldigestion • Insufficiency of the exocrine pancreas • chronic pancreatitis • pancreatic cancer • pancreatic resection • mucoviscidosis (= cystic fibrosis) • Lack of bile acid • reduced production • advanced hepatic cirrhosis • flow impairments: stenosis, gallstones, tumor • Lack of intestinal digestive enzymes • lactase • other disaccharidases • peptidases

5. Indication: Malabsorption • intestinal resection • Crohn´s disease/ulcerative colitis • diarrhea • disturbed intestinal perfusion • disturbed lymph flow • drugs Malabsorption • sprue = celiac disease

6. Contraindications absolute contraindications relative contraindications • shock of any genesis • metabolic disorders • acute pancreatitis • paralytic ileus (minimal nutrition possible) • high reflux-rate (minimal nutrition possible) • uncontrolled vomiting • persisting diarrhea - acute metabolic acidosis - acute serious hypoxia - acute serious respiratory insufficiency • acute abdomen - acute gastrointestinal bleeding - mechanical ileus

7. Dietary Foods for Special Medical Purposes (FSMP) Standard nutrient formulations or nutrient-adapted formulations for exclusive or partial feeding (1999/21/EG) Nutritionally Complete diet suitable as sole source of nourishment Nutritionally incomplete diet specific for a disease not suitable as the sole source of nourishment • Chemically-defined diet (CDD) • diet containing main nutrients completely or partly hydrolyzed Nutrient-defined diet (NDD) diet containing main nutrients (carbohydrates, fats, proteins) in their naturally occuring form

8. Characteristics of FSMP „Category of foods for particular nutritional uses specially processed formulated and intended for the dietary management of patients and to be used under medical supervision.“ (1999/21/EG) • energy density (kcal/mL) • energy ratio (protein : fat : carbohydrates) • balance of minerals, trace elements and vitamines • standard nutrient formulation or nutrient-adapted formulation specific for a disease • defined source of raw materials

9. Osmolarity  Osmolality Osmolarity: mOsm/L = number of osmotically active particles per liter solution (point of reference: volume) Osmolality: mOsm/kg = number of osmotically active particles per kg solution (point of reference: weight) Osmolality of blood plasma: 285-295 mOsm/kg

10. Standard Diets • high-molecular / high-polymeric (NDD) • dietary ratio corresponding to the recommendations • with / without dietary fibers • close to physiologic osmolarity adequate for patients with normal digestion and metabolism

11. Disease Specific Diets indication modification high caloric high energy need, fluid restriction diabetes mellitus starch, glucose substitutes, partly fat modified, rich in dietary fibers respiratory insufficiency, stress metabolism high lipid formulations maldigestion, malabsorption hepatic insufficiency, stress metabolism MCT content defined combination of fatty acids (relation of 3 : 6 : 9 fatty acids) impaired immune functions

12. Disease Specific Diets indication modification protein malnutrition, catabolism protein rich nephrology, pediatrics low protein addition of branched chain amino acids hepatic insufficiency special nutrition for fast proliferating cells (enterocytes, lymphocytes) high glutamine content addition of arginine and RNA disturbed wound healing,impaired immune functions

13. Advantages of an Early Enteral Nutrition • preserving the functions of the gut associated lymphatic tissue • maintaining the barrier of the intestinal mucosa • prevention of villous atrophy by endoluminal substrate induction and • improved perfusion in the splanchnic area • reduction of the pathological bacterial flora • improved prophylaxis against infections and sepsis • improved wound healing • stimulation of gastrointestinal hormones • early triggering of the intestinal motility • reduced loss of nitrogen (= loss of muscular tissue = loss of body weight) • prophylaxis against gastric / intestinal ulcers

14. Prophylaxis of Ulcers by Enteral Nutrition Gastric stress ulcers are typical intensive care complications Etiology • increased gastric acidification • reduced protective function of the mucosa • ulcer prophylaxis by antacids and H2-blocker intestinal bacterial flora overgrowth nosocomial pneumonia • ulcer prophylaxis by enteral nutrition physiological regulation of acid output  stimulation of protective mechanisms continuous administration is more effective than bolus injection Therapy

15. Enteral Routes • oral • nasogastral, nasoduodenal, nasojejunal short-term tube feeding • percutaneous endoscopically controlled gastrostomy (PEG) long-term tube feeding • fine needle catheter-jejunostomy (FNCJ) postoperative tube feeding

16. Feeding-Tube Positions Transnasal Feeding Tubes 1. nasointestinal feeding tube 2. nasogastric feeding tube Percutaneous Feeding Tubes 3. PEG 4. PEG with intestinal transfer tube 5. button 6. PEJ 7. FNCJ 1

17. Gastric Tube Feeding • normal gastric emptying Requirements • adequate protective reflexes • weak / missing protective reflexes • dysphagia of neurologic genesis • hiatal hernia (displacement of stomach) • reflux esophagitis Contraindications

18. Advantages of Gastric Nutrition • gastric reservoir function tolerance concerning quantity and osmolarity controlled nutrient passage into small intestine • bactericide effects of gastric acid • buffering of gastric acid by food

19. Duodenal / Jejunal Tube Feeding Indications • disturbed gastric emptying • gastric resection • reflux • vomiting • early postoperative diet Requirements • obligatory continuous administration (by pump): maximum 150 ml/h • endoscopic or radiological position control

20. Diameter and Length of Feeding Tubes • out-side diameter 5 – 32 FR (1 F =1/3 mm) • most frequently used: 8 – 15 FR • the smaller the diameter, the more convenient for the patient (function of the esophageal sphincter remains preserved) • in case of gravity administration  12 FR • 8 FR mostly in case of pump administration • 40 -250 cm length, with marks for x-ray control of position F = French (or Charriere)

21. Material of Feeding Tube PVC feeding tubes (polyvinylchloride) • only for short-term use, daily change necessary • dissolving of the softener, material is becoming hard and cracking • decreased function of the esophageal sphincter through rigid material  reflux of stomach contents

22. Material of Feeding Tubes PUR feeding tubes (polyurethane) • soft, flexible, no softener • little wall thickness • long term placement Silicone feeding tubes • long term placement • flexible without softener • in comparison to PUR feeding tubes: • thick tube walls are necessary to guarantee stability, • as a consequence the out-side diameter increases

23. Placement of Feeding Tubes Nasogastral: • local anesthesia of the nose • introduction as far as pharyngeal space, use of lubricant may be necessary • support of the esophageal passage by swallowing • slow introduction into the stomach • aspirate changes colour of pH-test paper into red • (acidic reaction of gastric acid) • insufflation and ausculation (administration of air into the feeding tube by a syringe) typical feeding tube • optional: x-ray control Control of position:

24. Placement of Feeding Tubes Nasoduodenal: • careful transpyloric introduction of feeding tube into the small intestine • endoscopic placement and control x-ray control Position control: Alternative method: • seldinger technique (placement over an endoscopically positioned guide wire)

25. PEG Feeding Tubes • long-term enteral nutrition in case of • cachexia • dysphagia • tumors in the head-neck area • multiple trauma • surgery Indications • gastric decompression and drainage

26. PEG Feeding Tube • Lack of diaphanoscopy • general disorders of wound healing and blood coagulation • peritonitis/peritoneal carcinosis • acute pancreatitis • pathological alterations of the gastric wall • ileus • sepsis • relative: Crohn´s disease and ascites • missing agreement of the patient Contraindications

27. Introduction of PEG („Keymling Method“) • introduction of the gastroscope, air insufflation, determination of the puncture site by diaphanoscopy (fig.1) • disinfection and anesthesia of the puncture site, advance puncture cannula into stomach under endoscopic control (fig. 2) • removal of the puncture needle, introduction of the thread into plastic cannula (fig. 3) • removal of the guide-thread by endoscope forceps (fig. 3) • fixation of the tube to guide thread by double knot (fig. 4) • retraction of the thread until the silicone disc of the tube stops at inner gastric wall (fig. 5) • fixation of plate, introduction of the clamp and the luer-lock connector (fig.6)

28. Introduction of PEG according to Keymling diaphanoscopy double knot fixation fig. 1 fig. 4 puncture tube placement fig. 2 fig. 5 external fixation guide thread insertion fig. 6 fig. 3

29. PEG Complications most common complications: • local wound infections • disturbed microcirculation in case of strong tension between inner and outer fixation plate • — necrosis and ingrown fixation plate • peritonitis • heavy bleeding because of vascular lesion during puncture rare complications:

30. Wound Dressing for PEG Feeding Tubes • slit and fleece compresses, fixation fleece • initially daily change, later once or twice a week • skin disinfection • loose fixation of the external fixation plate • daily rotation of the tube after ~ 14 days: formation of a stable fibrous channel

31. J-PEG tubes • placement of a intestinal tube (9 FR) through the already indwelling PEG tube 15 FR • assumption of the placement of a J-PEG tube • size of the lumen of the placed PEG tube: at least 15 FR • possibility of the navigation of the intestinal tube through pyloric and duodenal stenoses

32. J-PEG tubes • long-term intestinal feeding with simultaneous gastric decompression in patients with • loss of consciousness • gastric outflow obstruction • neurological dysphagia with risk of aspiration • pyloric and duodenal stenoses which can still be navigated by the intestinal tube • pancreatitis • hiatal hernias Indications • enteral nutrition during the early postoperative phase • intestinal recycling of bile with simultaneous gastric feeding

33. J-PEG tubes • lack of patient consent • Peritonitis / peritoneal carcinoma • mechanical Ileus distal to a jejunal tube • generalized disorders of coagulation Contraindications

34. Introduction of the J-PEG • removal of the Luer-Lock connector of the already placed PEG tube. Fixation of the Y-adapter (fig. 1 / 2) • placement of the intestinal tube via the intestinal leg („i“, green) (fig. 3) • Shortening of the intestinal tube and connection with the positive/negative Luer-Lock connector (fig. 4) • Connection of the tube with the Y-adapter of the PEG tube (fig. 4) • radiological checking of the tube position (or sonographic)

35. Introduction of the J-PEG

36. complications of the J-PEG tube • most comon complications: - dislocation of the intestinal tube • - gastric loop formation • - local wound infections related to the PEG •  further complications cf. PEG tube

37. Fine Needle-Catheter Jejunostomy (FNCJ) • postoperative enteral nutrition: • after open gastrointestinal surgery • for patients with multiple trauma Indications • long-term nutrition, • if introduction of PEG is impossible

38. Fine needle-catheter jejunostomy (FNCJ) • chronic and acute inflammation of the small and large intestine • mechanical ileus • peritonitis • acute pancreatitis • missing aggreement of the patient Contraindications

39. Introduction of FNCJ • Principle of the method • A fine needle-catheter jejunostomy is carried out during surgical interventions (laparotomy). • puncture of abdominal wall (fig. 1) • splitting and withdrawal of puncture needle (fig. 2) • puncture of jejunum and channeling (fig. 3) • fixation of tube (fig. 4)

40. Introduction of FNCJ puncture of jejunum puncture of abdominal wall splitting of puncture needle fixation

41. Ways of Enteral Feeding nutrient-intake continuous feedinglow flow rates- by pump bolus fast injection of 250-500 mL- by syringe intermittent feeding200 - 400 mL in 30 - 60 minutes- by gravity- by pump

42. Application Systems Connection with nutrient container • administration set with bottle-connection (screw cap / crown cork) • storage-bag with integrated set • spike application systems Connection with feeding tubes: • luer-lock • funnel / cone • luer-plug

43. Application Systems storage-bag bottle-connection

44. General requirements for a feeding-pump • small, light and handy • easy handling • easy setting and cleaning • easy introduction of the pump segments • quiet • operation by rechargeable battery • bag for mobile use • easy error analysis • acoustic und optic alarm in case of -occlusion - air in the application system - end of administration (volume, time) - low battery capacity - disorder of the equipment

45. Indications for Pump-Controlled Enteral Nutrition • slow and controlled start of enteral nutrition • early postoperative feeding • intestinal administration (obligatory) • pediatric enteral nutrition • gastrointestinal complications (disorders of gastric emptying, diarrhea, vomiting, etc.) • impaired digestion (for example: progressive tumors) • metabolic disorders (for example: complications in diabetes mellitus) • prophylaxis of aspiration (individual decision)

46. Patient Monitoring diagnosis andproblems of the patient requirements of the patient:- energy, - nutrients, - liquid tube feeding diet andway of administration

47. Patient Monitoring Start of tube feeding correct tube position control: x-ray, aspiration of gastric fluid (pH control), air insufflation adequate gastric emptying (control of aspirate volume) adequate protective reflexes skin and wound control

48. Patient Care elevated head of the patients bed (30 -45 degrees) temperature of tube feeding: room temperature rinsing of the feeding tube before and after feeding and medication define and control feeding time initially low dose / low rate correct medication (nutrient-drug-interactions) daily change of the application systems careof mouth and nose, stimulation of salivary secretion change of wound care kits keeping hygiene standard

49. Liquid Application  to cover liquid needs (taking the liquid-content of food into account)  to rinse the feeding tube   adequate inadequate • fresh tap water(if quality is adequate) • black teadiscolouring of the tube • mineral water without gas • beverages with gas or fruit acids(for example: coke, juice, fruit tea)tube clogging, sedimentations, flatulence ! In case of giving tea or preboiled water: do not leave vessel open, cool down covered, use fresh tea / water daily!

50. Rinsing of the Tube Rinse according to the length of the feeding tube by using 40 - 60 ml liquid (use 20 ml syringe) • before start of tube feeding • in case of interruption • during continuous supply: every 4-8 hours • after termination of tube feeding • before medication • after medication • in case of unused tube: once a day