Nutritional Support For The Critical Patient Andrea Collins, BBA, LVT, VTS (ECC)

Transcription

1 Nutritional Support For The Critical Patient Andrea Collins, BBA, LVT, VTS (ECC) TOPICS PART 1 Importance Indications for support Nutritional assessment Energy requirements The plan Enteral/Parenteral PART 2 TUBES! KEEPING IT SIMPLE NUTRITION IS IMPORTANT! Most important factor in restoring patient health Often overlooked Technicians should have an active role Instead of thinking they will eat when they feel better, let s replace that with they will feel better when they eat. MALNUTRITION 2 BASIC REQUIREMENTS Depressed immune system Decreased tissue synthesis and repair Those crazy electrolyte imbalances Altered drug metabolism Change in organ function Increased risk of morbidity & mortality ENERGY AND NUTRIENTS! 1

2 INDICATIONS FOR SUPPORT Anorexia or hyporexia lasting 3 or more days Always take into consideration how long patient was not eating prior to presentation Anticipated anorexia HOW WILL THEY EAT? NUTRITIONAL ASSESSMENT Overall body condition BCS/MCS Diet history Underlying disease Bloodwork values Organ function Current medications THE PLAN WE ARE THE ADVOCATE Determine the need Address underlying disease (diagnosis not required!) Choose appropriate method of delivery Gradually introduce Meet full goal within 72 hours Reassess frequently 2

3 RER ENTERAL IS BEST RER = 70 x (current BW in kg) 0.75 BW X BW X BW = = X 70 If they weigh between 3 and 25kg: (30 x kg) + 70 If the gut works, use it! Orally or via tube administration Prevents bacterial translocation Patients must be able to consume at least 85% of RER if relying on oral intake May need to supplement with PN TECHNICIAN ROLE ENTERAL ROUTES Take your time Quiet, calm area Appealing choices Bowl/plate/hand Social eater vs. closet eater Get creative Voluntary intake is best Force feeding Syringe feeding Tube feeding PARENTERAL ROUTES PARENTERAL OPTIONS When enteral is not an option Provides nutrients through a formulated solution Combination of amino acids, dextrose, lipids Absorbed by cells without passing through the gut first Can be used alone or in addition to enteral TPN Total parenteral nutrition Fulfills all nutrition requirements Requires central venous catheter Intensive monitoring Expensive Lack of nutrients to the gut PPN Partial parenteral nutrition Fulfills only part of requirements Does not always require a central catheter Commercially available solutions 3

4 PARENTERAL SOLUTIONS COMPLICATIONS TPN/PPN Procalamine B-vitamins Too much too soon. Begin with 50% RER Vomiting/diarrhea Fluid overload E-lyte imbalances Tube complications Infection SUMMARY All patients require energy and nutrients Determine the amount of support needed via a nutritional assessment Come up with a plan Calculate RER Monitor! Nutritional Support For The Critical Patient Part 2 - Tubes Andrea Collins, BBA, LVT, VTS (ECC) IF THE GUT WORKS, USE IT! INDICATIONS FOR TUBE FEEDINGS Voluntary intake is best but when not an option, tube feedings should be implemented Consider least expensive, least invasive method Special equipment not required for most Anorexia lasting 3 or more days or anticipated anorexia Persistent weight loss of more than 20% in less than 2 weeks CNS disorders Disorders of the oral cavity, pharynx, or esophagus Trauma, burns Existing disease (i.e. hepatic lipidosis, renal, diabetes) 4

5 OPTIONS OROGASTRIC Orogastric Nasoesophageal Nasogastric Gastrostomy/PEG Enterostomy(duodenostomy or jejunostomy) Typically used for neonates Easy to do if patient tolerates Inexpensive Red rubber catheter, syringe, food Measure from nose to 9 th rib Risks: stress, GIT trauma, aspiration NE/NG TUBES NE/NG TUBE Most commonly used at VTH For short-term nutritional support Inexpensive Non-invasive Can be left in place for several days to weeks Liquid diet required Contraindicated in patients with vomiting or respiratory disease, comatose Minimal supplies Tube cost $16-$20 Anesthesia not required Sedation may be necessary In-hospital use only ESOPHAGOSTOMY TUBE Longer term support Can be managed at home Simple surgical procedure Anesthesia required Tolerated well by most Gruel type diet Complications: aspiration, vomiting, tube expulsion, reflux, infection 5

6 GASTROSTOMY/PEG Long-term support Indicated when oral cavity, pharynx, or esophagus must be bypassed Can be managed at home General anesthesia required More expensive Advanced training PEG Percutaneous endoscopic gastrostomy Less invasive Allows for visualization of esophagus and stomach Endoscopic equipment Specialized training Gastrostomy Surgical procedure Useful during surgical exploratory Monitoring required COMPLICATIONS ENTEROSTOMY Stomal infection Blockage Tube dislodgment Peritonitis if leakage occurs Vomiting/diarrhea Duodenostomy or Jejunostomy Indicated when must bypass the stomach or duodenum Invasive Surgical procedure J through a G tube Can begin feeding shortly after surgery Complications: tube dislodgement, infection, kinking, clogging COMPARISON CASE EXAMPLE Tube Type Location Disease Costs Food Type Nasoesophageal Through the nose into the esophagus Short-term anorexia, supplemental $ Liquid only; bolus or CRI Nasogastric Through the nose into the stomach Short-term anorexia, supplemental $ Liquid only; bolus or CRI Esophagostomy Gastrostomy/PEG Enterostomy (jejunostomy/ duodenostomy) Placed surgically into the distal esophagus Placed surgically via laparotomy or endoscopy directly into the stomach. Placed surgically into the small intestine Hepatic lipidosis, anorexia, oral surgery or trauma, neoplasia Pancreatitis, hepatic lipidosis, anorexia, esophageal strictures, oral surgery or trauma, neoplasia Pancreatitis, intestinal anastomosis, coma, stomach surgery $$ Liquid, thin gruel; bolus or CRI $$$ Liquid, gruel; bolus or CRI $$$$ Liquid only 10 yr old F/S Chihuahua Presented for liver mass (also has underlying heart disease) Cardiac arrest during sedation for CT Resuscitated via CPR Now on full life support What type of nutritional support would be best? 6

7 CASE EXAMPLE ANSWER. 1yr old male german shepherd HBC multiple injuries to the mandible Dental bonding attempted but failed, tape muzzle placed and to remain for several weeks What type of nutritional support would be best? 7