NUTRITION. Elizabeth Viner Smith & Catherine Jones Foundations of Critical Care Nursing September 2017

Transcription

1 NUTRITION Elizabeth Viner Smith & Catherine Jones Foundations of Critical Care Nursing September 2017

2 Step One Competency 1.19 Factors contributing to nutritional impairment in critical illness. Nutritional assessment tool Local Nutrition Care Bundles Different Types of feeding & indications for use Oral NG/NJ/Gastrostomy (PEG/RIG) Parenteral Nutrition Insertion & Management of Ng Tubes. Types of NG feed Management of Parenteral Nutrition Bowel Management

3 Nutrition & Critical Illness Critical illness stress on body. METABOLIC RESPONSE Critical illness reduced/absent volitional intake STARVATION/ MALNUTRITION

4 Nutrition & Critical Illness Metabolic rate Starvation Injury / Disease Body fuels Conserved Wasted Body protein Conserved Wasted Urinary nitrogen Weight loss Slow Rapid The body adapts to starvation, but not in the presence of critical injury or disease

5 Nutrition & Critical Illness CRITICAL ILLNESS RESULTS IN INCREASED ENERGY EXPENDITURE AT A TIME OF IMPAIRED ENERGY SUPPLY.

6 Nutritional Risk Assessment Tool

7 Oral Nutrition

8 Oral Nutrition First preference. Need to consider the patient s level of consciousness, swallow & motivation. All can be impaired in critical illness If oral feeding is not sufficient to meet energy requirements within 3 days then enteral feeding should be initiated. Kreymann et. Al. (2006) ESPEN Guidelines on Enteral Nutrition: Intensive Care Clinical Nutrition 25 pp

9 Oral Nutrition

10 INGREDIENTS WITH ALLERGENS HIGHLIGHTED IN BOLD

11 Enteral Nutrition

12 THINK PURPLE ALWAYS USE A PURPLE SYRINGE FOR ORAL AND ENTERAL USE!!!!! ENFit ends enteral use only Draw up oral/enteral meds Administer oral enteral meds

13 NG Tube Insertion:

14 NEX measurement: Nose Ear Xiphisternum XEN + 10?? (Taylor et al 2014 Nasogastric Tube depth: the NEX guideline is incorrect British Journal of Nursing 23(12)

15 Cortrak

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17 IF POSITION NOT CONFIRMED APPLY THIS STICKER

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19 Case Study: SEQUENCE OF EVENTS 09:30 - Patient had an OGD *Due to the possibility of the NG becoming dislodged during the procedure, the nurse attempted to get an aspirate to test ph Referring to NG Guidance what would you do next? If possible turn pt onto left hand side Inject mls of air Advance Tube cm WAIT & Re-CHECK If still no aspirate DO NOT USE STICKER & CXR Acknowledgement:Tammy Stracey CTICU

20 Case Study: SEQUENCE OF EVENTS 11:30 CXR Done 12:00 CXR reviewed on the ward round and NG Tube placement confirmed to be in the stomach

21 SEQUENCE OF EVENTS 14:00 NG Aspirate of 20 mls obtained and found to have a ph 6.0 Referring to NG Guidance what would you do next? Look at Critical Care Risk Assessment: Risk of displacement coughing, vomiting? Tube length constant at nare? Respiratory deterioration? PPI, H2 receptor agonist?

22 SEQUENCE OF EVENTS No indication of the tube having moved after the CXR confirmation. Omeprazole IV BD 14:00 NG Feed 30 mls/hr 14:15 NG Medications given (Allopurinol, Aspirin, Ferrous Fumerate, Senna, Ticagrelor)

23 SEQUENCE OF EVENTS 20:00 On Assessment at Handover: Unable to obtain aspirate via NG No indication that tube had moved Previously absorbing well Blood stained secretions on suction Plan recheck at Referring to NG Guidance was the plan reasonable? If on continuous feed position to be checked once in 24 hour period unless concerned about tube position See Critical Care Risk Assessment

24 SEQUENCE OF EVENTS 22:00 The nurse prepared to give the patient his NG medications. Unable to obtain aspirate via NG Patient coughing Moderate creamy secretions on suction NG Tube seen to be coiled at back of mouth Referring to NG Guidance what would you do next? STOP FEED Any query about tube placement feeding should not commence Troubleshoot Tube??? CXR

25 CXR 00:55

26 DATIX Description of incident: Nurse could not aspirate NG prior to drug administration, patient started to cough & on suctioning looked like feed was coming through the ET tube, so stopped the feed & informed the DR. Chest X-ray was ordered & on X-ray it showed that the NG had migrated to Right lung, so NG removed & new NG was inserted. Action taken at time of incident: Stopped the feed & informed the DR. Chest X-ray was ordered & on X-ray it showed that the NG had migrated to Right lung, so NG removed & new NG was inserted.

27 POINTS TO NOTE Unlikely that the pt was fed into his lungs for a long period between 15:00 and 22:00 30ml/hour over 7 hours (=210ml) into R main bronchus would have caused severe respiratory compromise. Clinically, the patient didn t show signs of aspiration. The RIGHT sided consolidation seen on CXR was already seen on 19/08. The patient underwent a bronchoscopy on both the 21 st and 22 nd August - no signs of NG feed aspiration (blood and secretions only). After investigation and review it was felt that this was not a Never Event as the correct procedure was followed

28 LESSONS LEARNED Infrequent nursing documentation of NG placement (NG Tube length at the nose) and ph Check/document length at nose on 6hourly aspirate or if concerned ph check once per shift Working on both paper and computer based systems is a risk as documentation can be unclear Where some documentation was missing online there was some documentation on the ICU charts but this was not always the case It is debatable as to whether the NG Tube should have been removed immediately after it was found to be coiled in the back of the throat

29 Getting Started

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33 Early NG feeding beneficial to patient Start at 30ml/hr standard feed (Nutrison 1.0) Aspirate NGT 6 hourly (instead of 4) Increase rate of feed if aspirate <500ml Commence prokinetics if aspirates >500mls

34 Enteral Nutrition All patients who are not expected to be on full oral diet within 3 days should receive EN Patients who are haemodynamically stable with a functional GI Tract should be fed early within 24 hours Kreymann et. Al. (2006) ESPEN Guidelines on Enteral Nutrition: Intensive Care Clinical Nutrition 25 pp

35 Parenteral Nutrition

36 Parenteral Nutrition Indications: Unable to use gut abdominal trauma, extensive abdominal resection. Unable to achieve adequate enteral nutrition within 3 days of admission to critical care (ESPEN 2009).

37 Parenteral Nutrition Central or Peripheral? Monitor blood glucose & biochemistry. Use clean, dedicated line. Label Line For TPN ONLY Do not disconnect infusion unless infusion completed.

38 PN which ANTT?

39 Parenteral Nutrition Complications: Infection catheter related sepsis Pneumothorax; arterial puncture; line malposition insertion risks Hyperglycaemia - dextrose content Hyperlipidaemia lipid content Liver dysfunction Osteoperososis long term feeding Refeeding Syndrome Electrolyte Disturbances Volume overload KULICK & DEEN (2011) Specialised Nutrition Support American Family Physician 83;2

40 Refeeding & Bowels

41 Refeeding Syndrome Severe metabolic disturbance caused by the introduction of feed to starved or severely malnourished patients. Profound electrolyte disturbances Phosphate, Magnesium, Potassium. Can be fatal.

42 Refeeding syndrome: Criteria Adult Nutrition Support Policy One or More: BMI < 16kg/m Unintentional weight loss > 15% over past 3-6 months Little/no nutritional intake > 10 days. Low levels K+, Phosphate, Magnesium Two or more: BMI < 18.5kg/m Unintentional weight loss > 10% over past 3-6 months Little/no nutritional intake > 5 days. History of alcohol/drug dependency. Medications insulin, chemo, antacids, diuretics. NICE (2006) Nutrition Support in Adults

43 Refeeding syndrome Actions: Conservative introduction of nutrition. Restore & monitor circulating volume. Pabrinex (IV) or Thiamine TDS & Vit B co-strong 1-2 tablets OD Multivitamin OD Monitor & replace potassium, phosphate & magnesium NICE (2006) Nutrition Support in Adults/ St George s Hospital Trust Policy

44 Questions??

45 References Singer et al (2009) ESPEN Guidelines on Parenteral Nutrition: Intensive Care Clinical Nutrition 28. Clain et al (2015) Glucose Control in critical Care World Journal of Diabetes 6(9)