Objectives

Review ASPEN guidelines and grading system Review various modes of nutrition support

Clinical indications/contraindications
Benefits of Enteral Nutrition Parenteral Nutrition appropriateness

A.S.P.E.N
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N) is dedicated to improving patient care by advancing the science and practice of nutrition support therapy
More than 5,500 members from around the world consisting of dietitians, nurses, physicians, students, pharmacists, and other health professionals A.S.P.E.N Recommendations Task Force examines the available literature related to the ordering, preparation, delivery, and monitoring of enteral/parenteral nutrition and establishes evidence-based practice guidelines.

The evidence supporting each recommendation is classified as follows:

A: Guidelines supported by at least two level I investigations (large, randomized trials) B: Fair research-based evidence to support the guideline (supported by one level I investigation) C: Guideline is based on expert opinion and editorial consensus (supported by level II investigations only- small, randomized trials) D: Guideline is supported by at least two level III investigations (nonrandomized, contemporaneous controls) E: Guideline supported by level IV or level V evidence (non randomized, historical controls, case series, uncontrolled studies, expert opinion)

Enteral Nutrition (tube feeding)

Short Term (<4 weeks): NGT, OGT, NJT, Long Term: G-tube, J-tube, PEG, PEG-J

Clinical Indications
1. Access to an adequately functioning gastrointestinal tract

2.

Insufficient oral intake or impaired nutrient digestion, absorption, or metabolism Neurological disorders (ex. CVA with dysphagia) Severe gastroparesis Hyperemesis gravidarum Short bowel syndrome with >200 cm bowel remaining

3. Need is expected for >5-7 days for malnourished patients or 7-9 days for adequately nourished

Clinical Contraindications
1. 2. 1. Nonoperative mechanical GI obstruction Intractable vomiting/diarrhea refractory to medical management Severe short-bowel syndrome (less then 200 cm remaining)

2.
3. 4. 5. 6.

Paralytic ileus
high-output enterocutaneous fistula Severe GI bleed or severe GI malabsorption Inability to gain access Aggressive intervention not warranted

ASPEN Guidelines: Critical Care

Nutrition support therapy in the form of enteral nutrition (EN) is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who requires nutrition support therapy (Grade B) Enteral feeding should be started early within the first 24-48 hours following admission (Grade C). The feedings should be advanced towards goal over the next 48-72 hours

In the setting of hemodynamic compromise, EN should be withheld until the patient is fully resuscitated and/or stable (Grade E)
In the ICU patient population, neither the presence nor absence of bowel sounds nor evidence of passage of flatus and stool is required for the initiation of enteral feeding (Grade B) Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing intolerance of gastric feeding (Grade C).

Complications/Risks of EN
Nasopharyngeal irritation and pain

Tube migration or dislodgement

GI obstruction from dislodged components of tube Tube occulusion Leakage, irritation or infection around the feeding site Peritonitis Fistulas Aspiration pneumonia

Benefits of Enteral Nutrition

EN preserves gut integrity EN supports the structural integrity of the IgA producing immunocytes which comprise the GALT and in turn contributes to MALT at distant sites- lungs, liver, and kidneys Loss of functional gut integrity leads to increased permeability and increased risk of infection and MODS

Research shows less infectious morbidity, fewer infectious complications, and significant cost savings compared to PN

Parenteral Nutrition TPN PPN PICC

Clinical Indications
1. Documented inability to absorb adequate nutrients via the GI tract such as: Massive small-bowel resection (<200 cm remaining) Inability to obtain enteral access Pancreatitis accompanied by abdominal pain with jejunal delivery of nutrients Persistent GI hemorrhage Acute abdomen/ileus Intractable vomiting/diarrhea High output enterocutaenous fistula (>500 mL)

Contraindications for Parenteral Nutrition

Functioning gastrointestinal tract
Treatment anticipated for less than 5 days in patients without severe malnutrition Inability to obtain venous access A prognosis that does not warrant aggressive nutrition support When the risks of PN are judged to exceed the potential benefits

Central Line vs. Peripheral

PPN contains a lower concentration of nutrients compared to Central PN The osmolarity of PPN must not exceed 900 mOsm/L PPN is not appropriate for patients on a fluid restriction. Adults require large fluid volumes to deliver adequate nutrition support. PPN is only indicated for short term use It can prevent malnutrition but it will not correct existing nutritional deficits

ASPEN Guidelines: Critical Care

If early EN is not feasible or available over the first 7 days following admission to the ICU, no nutrition support therapy should be provided (Grade C). In the patient who was previously healthy prior to critical illness with no evidence of protein-calorie malnutrition, use of PN should be reserved and initiated only after the first 7 days of hospitalization (when EN is not available) (Grade E). If there is evidence of protein-calorie malnutrition on admission and EN is not feasible, it is appropriate to initiate PN as soon as possible following admission and adequate resuscitation (Grade C). If a patient is expected to undergo major upper GI surgery and EN is not feasible, PN should be provided under very specific conditions: If the patient is malnourished, PN should be initiated 5-7 days pre-operatively and continued into the post-operative period (Grade B) PN should not be initiated in the immediate post-operative period, should be delayed for 5-7 days (should EN continue not to be feasible) PN therapy provided for a duration of less than 5-7 days would be expected to have no outcome effect and may result in increased risk to the patient (Grade B)

Complications/Risks of PN
Central line associated bloodstream infections

Thrombosis
PN associated liver disease Pneumonia

Fungemia
Sepsis Pneumothorax Volume overload Acid base imbalance Metabolic Bone Disease (long term use)

Nutrition Support: Collaboration

Nutrition support teams have been shown to improve patient outcomes Increasing collaboration through nutrition support teams decreases the use of inappropriate parenteral nutrition therapy Inappropriate=not in accordance with A.S.P.E.N. Inappropriate PN costs $!

The Intervention
Policy initiated to require pharmacy to inform RDs about new PN patients Intern presented educational presentation at nutrition support committee meeting about the importance of ASPEN guidelines and interdisciplinary collaboration

The Study
Retrospective chart review examining each PN patient post intervention and determining if PN was appropriate and if RD was consulted
Does the intervention succeed in increasing interdisciplinary collaboration between physicians, dietitians, and surgeons? Does it succeed in increasing the appropriate percentage of PN? Is interdisciplinary collaboration (nutrition consults) related to the appropriate use of PN?

Pre-Intervention
Month % of Appropriate PN % of Inappropriate % Receiving Nutrition Consults 53% 44% 56% 51% % of Cases not Receiving Nutrition Consults 47% 56% 44% 49% Total # of Cases

November 2012 December 2012 January 2013 Mean

73% 44% 72% 63%

27% 56% 28% 37%

15 9 18 14

Post-Intervention
Month % of Appropriate PN % of Inappropriate % Receiving Nutrition Consults 50% 62% % of Cases not Receiving Nutrition Consults 50% 38% Total # of Cases

February 2013 March 2013

61% 62%

39% 38%

18 13

Mean

62%

39%

56%

44%

16

Statistical Analysis: Pearson Chi-Square PN and Nutrition Consults November 2012March 2013
X^2=8.47 df=1 P<.0036
% of appropriate PN with nutrition consult % of appropriate PN with no consult % of inappropriate PN with nutrition consult % of inappropriate PN with no nutrition consult Total % of appropriate PN Total % of inappropriate PN 66% 34% 31% 69% 64% 36%

Case Study
52 YOM with a PMHx significant for PVD and Crohns disease p/w abdominal pain and two enterocutaneous fistulas (draining 600 ml x 24 hours). Pt reports inability to tolerate PO x 6 weeks. BMI: 17.9, prealbumin 9.2 mg/dl

Answer
A high output fistula is an indicator for PN. TPN reduces GI secretions thereby not exacerbating the output EN is possible for non high output fistulas. If the fistula is in a proximal location, pts can be fed enterally distal to the fistula using a PEG/J or an NJ tube. If the fistula is very distal- such as distal ileal or colonic, the patient can potentially obtain full nutrition by mouth or via gastric tube. If the fistula is located in the small bowel too distal for a PEG/J to pass, yet not distal enough to allow adequate enteral absorption proximal to the fistula, then the possibility of fistuloclysis can be considered. Fistuloclysis= placing a feeding tube directly into the fistula (there must be enough unobstructed bowel distal to the fistula in continuity for adquate nutrient absorption.
Willcutts, K. The Art of Fistuloclysis: Nutritional Management of Enterocutaneous Fistulas. Practical Gastroenterology. September 2010.http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutritionsupport-team/nutrition-articles/WillcuttsArticle.pdf

Case Study
82 YOF with PMHx significant for DM, PVD gastroparesis, aspiration PNA, frequent falls, and advanced vascular dementia is admitted from NH after being found aspirating on her lunch. SLP saw pt, recommended NPO with alternative form of nutrition.

Answer
Nutrition support in patients with advanced dementia has not been shown to promote the healing of pressure ulcers, reduce the risk of aspiration PNA, increase patient comfort, functional status, or prolong survival when compared to hand-feeding. In 1999 Finucane and colleagues noted in a review of the literature that enteral nutrition did not improve clinical outcome in advanced dementia, in 2008 a Cochrane review concluded that there was insufficient evidence to suggest that enteral nutrition benefits patients with advanced dementia. Both studies concluded that there is little efficacy for enteral nutrition in this population. Many families and clinicians misunderstand or overestimate the benefits of nutrition support in advanced dementia. This can lead to ethical dilemmas. Evidenced based education and counseling can constructively address these dilemmas.

Barrocas A, Geppert C, Durfee SM, et al. ASPEN Ethics Position Paper. December 2010. https://www.nutritioncare.org/Index.aspx?id=5850

Case Study
67 YOM with Stage III supraglottic laryngeal cancer T3-N1-M0 s/p neck dissection and total laryngectomy. Plan to begin XRT in 3 weeks . PMHx significant for etoh abuse and tobacco use.

Answer
Use enteral nutrition to increase calorie and protein intake for outpatients with stage III or IV head and neck cancer undergoing intensive radiation treatment. Maintenance of nutritional status by EN during radiation therapy may improve tolerance to therapy to promote better outcomes.

AND Evidence Analysis Library; Rating: Strong. http://andevidencelibrary.com/template.cfm?key=1754&auth=1 Based on 2 positive quality RCTs

Case Study
59 YOF with a pmhx etoh abuse, p/w nausea, vomiting, and abdominal pain radiating to her back. Pts admitting diagnosis is severe pancreatitis. Today is hospital day #8, NPO day 9. Pt transitioned to CLD yesterday but did not tolerate.

Answer
Patients with mild to moderate acute pancreatitis do not require nutrition support therapy (unless an unexpected complication develops or there is failure to advance to oral diet within 7 days (Grade C) Patients with severe acute pancreatitis may be fed enterally by the gastric or jejunal route (Grade C)
Martindale et al. Crit Care Med 2009 Vol. 37, No. 5

Case Study
27 YOF G1P0 at 10 weeks gestation, p/w nausea and vomiting x 4 weeks. PMHx significant for DM. Height: 55 Pre pregnancy Weight: 180#. Pt unable to tolerate PO intake for 4 weeks, current weight: 170#

Answer
If a woman with HEG has not responded to dietary modifications, hydration, and oral antiemetics, EN should be initiated via NGT or NJT. So far, gastric EN appears to offer more rapid relief of nausea and emesis compared to small bowel feedings. Studies have found that EN has offered significant relief from n/v and has led to positive fetal outcomes.

The use of PN in these patients should be avoided if possible. Pregnancy suppresses the immune system putting them at even greater risk for central venous catheter related bacterial and fungal sepsis. Pregnant women also have elevated coagulation factors making them more prone to catheter related thromboembolism. Cost of solution, compounding, and infusion supplies for PN is estimated at $1400 per week. The estimated cost for home EN is $56 per week.
Lord LM, Pelletier K. Management of Hyperemesis Gravidarum with Enteral Nutrition. Nutrition Issues in Gastroenterology, Series #63. Practical Gastroenterology. June 2008