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Extended indications for enteral nutritional support
INTERNATIONAL WARD ROUNDS IN CLINICAL NUTRITION
Editors: George L. Blackburn, MD Gordon L. Jensen, MD, PhD
Extended Indications for Enteral Nutritional Support Chitra Mahesh, BSc, CNSD, Krishnan Sriram, MBBS, FRCS(C), FACS, and V. Lakshmiprabha, BSc, CNSD From the Tamilnad Hospital; and the Sri Ramachandra Medical College and Research Institute, Chennai, India With the availability of an organized nutrition support team (NST), the use of enteral nutrition (EN) can be extended to patients who would have otherwise received parenteral nutrition (PN). Although the formulation and accuracy of nutrient intake seems easier with PN, it is accepted that EN is cost effective and advantageous and should be used whenever possible. We discuss three cases in which the NST was initially consulted to provide PN. After evaluation by the dietitian, gastrointestinal access was obtained by the NST physician and EN could be initiated. The case studies show that an organized NST consisting of knowledgable members can extend the use of EN to patients who would have otherwise received PN. The cost saving of such an approach and its efficacy in clinical practice are obvious. Nutrition 2000;16: 129 –130. ©Elsevier Science Inc. 2000 Key words: nutrition support team, enteral nutrition, parenteral nutrition, gastrointestinal access
INTRODUCTION When the services of an organized nutrition support team (NST) are used, the use of enteral nutrition (EN) can be extended to patients who would have otherwise received parenteral nutrition (PN). We discuss three cases in which the nutrition support service (NSS) was initially consulted for PN. By using aggressive measures to obtain gastrointestinal access, all patients were successfully managed on EN.
CASE REPORTS Case 1 A 26-y-old male was admitted with complaints of altered sensorium and vomiting of 1 wk duration after heat exposure a few days previously. Weight at admission was 56 kg (height ⫽ 177 cm, ideal body weight ⫽ 77 kg). Basic and laboratory tests showed mild nutritional depletion (albumin ⫽ 4.5 g/dL, total lymphocyte count ⫽ 1160 cells/mm3). Oral intake was negligible. He was supplemented with peripheral PN providing 30 non-protein calories/kg body weight and 1.2 g protein/kg body weight, on which he was managed for 5 d, while work-up was continued. Based on increasing volumes of gastric aspirate, the primary service made a diagnosis of gastroparesis. This was unresponsive to conventional medications, and the NST was consulted for PN. However, it was felt that duodenal or jejunal feeding could be attempted. Accordingly a nasoenteral (NE) tube (no. 12, 109 cm, polyurethane, radiopaque tube and tip; Corpak Med Systems, Wheeling, IL, USA) was positioned in the third part of the duodenum under fluoroscopy. Subsequently, radiologic examination confirmed that the tip was located at the level of the ligament of Treitz. Enteral feeding was initiated with a polymeric formula (Resource, Novartis Nutrition, Thane, India) using an intermittent
Correspondence to: Krishnan Sriram, MBBS, FRCS(C), FACS, Department of Surgery, SRMC (DU), Porur, Chennai 600116, India. E-mail: [email protected] Nutrition 16:129 –130, 2000 ©Elsevier Science Inc., 2000. Printed in the United States. All rights reserved.
feeding method (4 h on and 4 h off). Feedings were started slowly and gradually increased to provide 35 non-protein kcal and 1.13 g protein/kg body weight. He was also given multivitamins and trace elements to meet the required dietary allowances. Improvements in all biochemical parameters were noted at reassessment in 10 d. Electrolyte and renal parameters remained normal throughout. After about 30 d, the sensorium had improved. The patient was able to consume small quantities of clear liquids by mouth under supervision. He was discharged home on NE feeding with plans to perform a feeding jejunostomy if oral intake did not improve. Oral intake did improve and diet could be gradually increased over the next 2 mo. Supplemental nocturnal NE feedings were continued during this time and then discontinued. Six months after the initial episode, except for mild personality changes, the patient was doing well.
Case 2 A 19-y-old male underwent laparotomy for blunt abdominal trauma. Left nephrectomy was performed for irreparable damage to the renal vessels. A retroperitoneal hematoma was evacuated. An NE (same details as in case 1) was placed intraoperatively, with the tip in the second part of the duodenum. EN was initiated on the day after surgery but was not tolerated. Contrast studies showed partial obstruction at the duodenojejunal junction due to a hematoma. The NSS was consulted for PN. It was felt that if gastrointestinal (GI) access beyond the site of obstruction could be obtained, albeit with some difficulty, PN could be avoided. Because the length of the standard NE tube was not sufficient, an angiogram guidewire (no. 0.28, 350 cm) was inserted transnasally and positioned in the proximal jejunum under fluoroscopy. An angiogram catheter (6-French, 200 cm) was inserted, and the guidewire was removed. Catheter tip position was confirmed. The patient received EN with an elemental formula (Pepti 2000, Nutricia, The Netherlands). A polymeric formula was started after 5 d. Nasogastric drainage had diminished within 10 d, and contrast study confirmed resolution of the obstruction. Oral diet was started, and EN was administered as a transitional feeding only at night for 5 0899-9007/00/$20.00 PII S0899-9007(99)00250-6
130 additional d before the catheter was removed. There was no weight loss, and all laboratory parameters were preserved. The patient has done well several months after the injury. Case 3 A 82-y-old male, with known history of squamous cell carcinoma of the middle third of the esophagus, was admitted with complaints of dysphagia to solids. Weight was 46 kg (height ⫽ 152 cm, ideal body weight ⫽ 52 kg). The NST was consulted for PN because an NE tube could not be inserted. It was felt by the NST that PN could be avoided if GI access could somehow be obtained. The patient was elderly and malnourished, and the tumor was advanced. A feeding gastrostomy was felt to be contraindicated. A guidewire was passed through the narrow esophageal lumen under fluoroscopic control, and the stomach was entered. A polyvinyl chloride nasogastric tube (no. 10) was inserted over the guidewire. He was provided a polymeric formula (Resource, Novartis Nutrition) as a supplement. Feedings were initiated with 24 non-protein kcal and 0.92 g protein/kg body weight and were increased gradually to provide 35 non-protein kcal and 1.76 g protein/kg body weight at the time of discharge. He was also given multivitamins and trace elements to meet the recommended dietary allowances. Although weight gain was not noted at the end of 30 d, albumin and total lymphocyte count improved. His family took him back to his village for terminal care at home and he was lost to follow up.
DISCUSSION In patients in whom GI access is not easily obtained, physicians not experienced in nutrition support find it easier to administer PN. In the cases discussed, PN may seem justified after a cursory evaluation of the patient. In case 1, an NE tube was first inserted rather than a jejunostomy because we expected that the gastroparesis would resolve. Fortunately, the patient improved. A feeding jejunostomy would have been ideal, but the family had declined. With meticulous attention to EN procedures, we could maintain the patient on EN successfully. In case 2, it was anticipated that the hematoma causing bowel obstruction would resolve. As expected, after a few days of NE feeding, oral intake could be resumed. In case 3, although PN could be justified in patients with esophageal carcinoma with near total obstruction, the NST was confident that GI access could be obtained, and EN was initiated.
EXTENDED INDICATIONS FOR ENTERAL NUTRITION
BENEFITS OF EN In recent years, the use of EN in critically ill patients has been emphasized.1 The usefulness of EN is well known and accepted. EN has gained favor in view of its low complication rate, simplicity of delivery, and low cost.2,3 EN promotes mucosal growth and development, improves absorptive capacity, alters digestive enzyme production, increases gut DNA, protein synthesis, and mucosal weight, and improves the efficiency of nutrient utilization and visceral protein synthesis.4 In addition, EN maintains gut mucosal integrity and immunologic competence.5 It is an old adage that the gut should be used whenever possible. Studies have proved that a team approach decreases complication rates in both PN and EN.6,7 An NST also results in more appropriate use of PN by early resumption of EN. Cost saving from NSTs has been well accepted.8 Were it not for the aggressive approach of our NST, all the three patients would have been on PN, with added cost and possibility of complications. We recommend that all secondary and tertiary care hospitals have access to physicians and dieticians with interest and expertise in nutritional support.
CONCLUSION These case studies suggest that an NSS can extend the use of EN to patients who would have otherwise received PN. The cost saving of such an approach and its efficiency in clinical practice are obvious.
REFERENCES 1. Frost P, Bihari D. The route of nutritional support in the critically ill: physiological and economical considerations. Nutrition 1997;13(suppl 9):585 2. Schwartz DB. Enhanced enteral and parenteral nutrition practice and outcomes in an intensive care unit with a hospital-wide performance improvement process. J Am Diet Assoc 1996;96:484 3. Szelugu DJ, Stuart RRD, Brookmeyer R, et al. Nutritional support of bone marrow transplant recipients: a prospective randomized clinical trial comparing total parenteral nutrition and enteral feeding program. Cancer Res 1987;47:3309 4. Barton RG. Nutrition support in critical illness. Nutr Clin Prac 1994;9:127 5. Minard C. Enteral access. Nutr Clin Prac 1994;9:172 6. Dalton NJ, Schepers G, Gee JP. Consultative total parenteral nutrition teams: the effect on the incidence of total parenteral nutrition related complications. JPEN 1984;8:146 7. Brown RO. Enteral nutritional support management in a university teaching hospital—team versus non-team. JPEN 1987;11:52 8. Nelson JK. Economics of nutritional support. In: Matarese LE, Gottschliah MM, eds. Contemporary nutrition practice. Philadelphia: WB Saunders, 1998:643
Editors: George L. Blackburn, MD Gordon L. Jensen, MD, PhD
Extended Indications for Enteral Nutritional Support Chitra Mahesh, BSc, CNSD, Krishnan Sriram, MBBS, FRCS(C), FACS, and V. Lakshmiprabha, BSc, CNSD From the Tamilnad Hospital; and the Sri Ramachandra Medical College and Research Institute, Chennai, India With the availability of an organized nutrition support team (NST), the use of enteral nutrition (EN) can be extended to patients who would have otherwise received parenteral nutrition (PN). Although the formulation and accuracy of nutrient intake seems easier with PN, it is accepted that EN is cost effective and advantageous and should be used whenever possible. We discuss three cases in which the NST was initially consulted to provide PN. After evaluation by the dietitian, gastrointestinal access was obtained by the NST physician and EN could be initiated. The case studies show that an organized NST consisting of knowledgable members can extend the use of EN to patients who would have otherwise received PN. The cost saving of such an approach and its efficacy in clinical practice are obvious. Nutrition 2000;16: 129 –130. ©Elsevier Science Inc. 2000 Key words: nutrition support team, enteral nutrition, parenteral nutrition, gastrointestinal access
INTRODUCTION When the services of an organized nutrition support team (NST) are used, the use of enteral nutrition (EN) can be extended to patients who would have otherwise received parenteral nutrition (PN). We discuss three cases in which the nutrition support service (NSS) was initially consulted for PN. By using aggressive measures to obtain gastrointestinal access, all patients were successfully managed on EN.
CASE REPORTS Case 1 A 26-y-old male was admitted with complaints of altered sensorium and vomiting of 1 wk duration after heat exposure a few days previously. Weight at admission was 56 kg (height ⫽ 177 cm, ideal body weight ⫽ 77 kg). Basic and laboratory tests showed mild nutritional depletion (albumin ⫽ 4.5 g/dL, total lymphocyte count ⫽ 1160 cells/mm3). Oral intake was negligible. He was supplemented with peripheral PN providing 30 non-protein calories/kg body weight and 1.2 g protein/kg body weight, on which he was managed for 5 d, while work-up was continued. Based on increasing volumes of gastric aspirate, the primary service made a diagnosis of gastroparesis. This was unresponsive to conventional medications, and the NST was consulted for PN. However, it was felt that duodenal or jejunal feeding could be attempted. Accordingly a nasoenteral (NE) tube (no. 12, 109 cm, polyurethane, radiopaque tube and tip; Corpak Med Systems, Wheeling, IL, USA) was positioned in the third part of the duodenum under fluoroscopy. Subsequently, radiologic examination confirmed that the tip was located at the level of the ligament of Treitz. Enteral feeding was initiated with a polymeric formula (Resource, Novartis Nutrition, Thane, India) using an intermittent
Correspondence to: Krishnan Sriram, MBBS, FRCS(C), FACS, Department of Surgery, SRMC (DU), Porur, Chennai 600116, India. E-mail: [email protected] Nutrition 16:129 –130, 2000 ©Elsevier Science Inc., 2000. Printed in the United States. All rights reserved.
feeding method (4 h on and 4 h off). Feedings were started slowly and gradually increased to provide 35 non-protein kcal and 1.13 g protein/kg body weight. He was also given multivitamins and trace elements to meet the required dietary allowances. Improvements in all biochemical parameters were noted at reassessment in 10 d. Electrolyte and renal parameters remained normal throughout. After about 30 d, the sensorium had improved. The patient was able to consume small quantities of clear liquids by mouth under supervision. He was discharged home on NE feeding with plans to perform a feeding jejunostomy if oral intake did not improve. Oral intake did improve and diet could be gradually increased over the next 2 mo. Supplemental nocturnal NE feedings were continued during this time and then discontinued. Six months after the initial episode, except for mild personality changes, the patient was doing well.
Case 2 A 19-y-old male underwent laparotomy for blunt abdominal trauma. Left nephrectomy was performed for irreparable damage to the renal vessels. A retroperitoneal hematoma was evacuated. An NE (same details as in case 1) was placed intraoperatively, with the tip in the second part of the duodenum. EN was initiated on the day after surgery but was not tolerated. Contrast studies showed partial obstruction at the duodenojejunal junction due to a hematoma. The NSS was consulted for PN. It was felt that if gastrointestinal (GI) access beyond the site of obstruction could be obtained, albeit with some difficulty, PN could be avoided. Because the length of the standard NE tube was not sufficient, an angiogram guidewire (no. 0.28, 350 cm) was inserted transnasally and positioned in the proximal jejunum under fluoroscopy. An angiogram catheter (6-French, 200 cm) was inserted, and the guidewire was removed. Catheter tip position was confirmed. The patient received EN with an elemental formula (Pepti 2000, Nutricia, The Netherlands). A polymeric formula was started after 5 d. Nasogastric drainage had diminished within 10 d, and contrast study confirmed resolution of the obstruction. Oral diet was started, and EN was administered as a transitional feeding only at night for 5 0899-9007/00/$20.00 PII S0899-9007(99)00250-6
130 additional d before the catheter was removed. There was no weight loss, and all laboratory parameters were preserved. The patient has done well several months after the injury. Case 3 A 82-y-old male, with known history of squamous cell carcinoma of the middle third of the esophagus, was admitted with complaints of dysphagia to solids. Weight was 46 kg (height ⫽ 152 cm, ideal body weight ⫽ 52 kg). The NST was consulted for PN because an NE tube could not be inserted. It was felt by the NST that PN could be avoided if GI access could somehow be obtained. The patient was elderly and malnourished, and the tumor was advanced. A feeding gastrostomy was felt to be contraindicated. A guidewire was passed through the narrow esophageal lumen under fluoroscopic control, and the stomach was entered. A polyvinyl chloride nasogastric tube (no. 10) was inserted over the guidewire. He was provided a polymeric formula (Resource, Novartis Nutrition) as a supplement. Feedings were initiated with 24 non-protein kcal and 0.92 g protein/kg body weight and were increased gradually to provide 35 non-protein kcal and 1.76 g protein/kg body weight at the time of discharge. He was also given multivitamins and trace elements to meet the recommended dietary allowances. Although weight gain was not noted at the end of 30 d, albumin and total lymphocyte count improved. His family took him back to his village for terminal care at home and he was lost to follow up.
DISCUSSION In patients in whom GI access is not easily obtained, physicians not experienced in nutrition support find it easier to administer PN. In the cases discussed, PN may seem justified after a cursory evaluation of the patient. In case 1, an NE tube was first inserted rather than a jejunostomy because we expected that the gastroparesis would resolve. Fortunately, the patient improved. A feeding jejunostomy would have been ideal, but the family had declined. With meticulous attention to EN procedures, we could maintain the patient on EN successfully. In case 2, it was anticipated that the hematoma causing bowel obstruction would resolve. As expected, after a few days of NE feeding, oral intake could be resumed. In case 3, although PN could be justified in patients with esophageal carcinoma with near total obstruction, the NST was confident that GI access could be obtained, and EN was initiated.
EXTENDED INDICATIONS FOR ENTERAL NUTRITION
BENEFITS OF EN In recent years, the use of EN in critically ill patients has been emphasized.1 The usefulness of EN is well known and accepted. EN has gained favor in view of its low complication rate, simplicity of delivery, and low cost.2,3 EN promotes mucosal growth and development, improves absorptive capacity, alters digestive enzyme production, increases gut DNA, protein synthesis, and mucosal weight, and improves the efficiency of nutrient utilization and visceral protein synthesis.4 In addition, EN maintains gut mucosal integrity and immunologic competence.5 It is an old adage that the gut should be used whenever possible. Studies have proved that a team approach decreases complication rates in both PN and EN.6,7 An NST also results in more appropriate use of PN by early resumption of EN. Cost saving from NSTs has been well accepted.8 Were it not for the aggressive approach of our NST, all the three patients would have been on PN, with added cost and possibility of complications. We recommend that all secondary and tertiary care hospitals have access to physicians and dieticians with interest and expertise in nutritional support.
CONCLUSION These case studies suggest that an NSS can extend the use of EN to patients who would have otherwise received PN. The cost saving of such an approach and its efficiency in clinical practice are obvious.
REFERENCES 1. Frost P, Bihari D. The route of nutritional support in the critically ill: physiological and economical considerations. Nutrition 1997;13(suppl 9):585 2. Schwartz DB. Enhanced enteral and parenteral nutrition practice and outcomes in an intensive care unit with a hospital-wide performance improvement process. J Am Diet Assoc 1996;96:484 3. Szelugu DJ, Stuart RRD, Brookmeyer R, et al. Nutritional support of bone marrow transplant recipients: a prospective randomized clinical trial comparing total parenteral nutrition and enteral feeding program. Cancer Res 1987;47:3309 4. Barton RG. Nutrition support in critical illness. Nutr Clin Prac 1994;9:127 5. Minard C. Enteral access. Nutr Clin Prac 1994;9:172 6. Dalton NJ, Schepers G, Gee JP. Consultative total parenteral nutrition teams: the effect on the incidence of total parenteral nutrition related complications. JPEN 1984;8:146 7. Brown RO. Enteral nutritional support management in a university teaching hospital—team versus non-team. JPEN 1987;11:52 8. Nelson JK. Economics of nutritional support. In: Matarese LE, Gottschliah MM, eds. Contemporary nutrition practice. Philadelphia: WB Saunders, 1998:643