1. ENTERAL AND PARENTERAL NUTRITION UPDATE WITH THE NUTRITION CARE PROCESS Suzanne Neubauer, PhD,RD,CNSC Framingham State University Overlook Health Center, Charlton, MA January 31, 2013

2. Objectives  Identify proposed etiology based adult malnutrition definitions.  Using the AND evidence analysis library, state best practices for enteral and parenteral nutrition, including permissive underfeeding, BG control, GI complications (aspiration, delayed gastric emptying, diarrhea), administration protocol.

3. Objectives  Calculate basic flow rates for enteral nutrition considering interruption factors and fluid needs.  Calculate parenteral nutrition formulas, including basic electrolyte considerations.  Practice the nutrition care process for enteral/parenteral cases, focusing on new nutrition diagnosis and intervention standardized language.

4. Objectives  Identify proposed etiology based adult malnutrition definitions.  Using the AND evidence analysis library, state best practices for enteral and parenteral nutrition, including permissive underfeeding, BG control, GI complications (aspiration, delayed gastric emptying, diarrhea), administration protocol.

5. History for Etiology Based Malnutrition  only 3% of patients admitted to acute care settings in the US are diagnosed with malnutrition (2009)  primary ICD-9 code used: 263.9 Protein-Calorie Malnutrition, NOS (not otherwise specified)  Suggest change current language to make it consistent with an etiology based malnutrition diagnosis  CMS has also questioned the use of acute phase serum proteins as primary diagnostic criteria for malnutrition  Studies suggest there is limited correlation of acute phase proteins with nutrition status Acute phase proteins may be a measure of inflammation

6. Adult Malnutrition: Identify ≥ 2 of 6 Characteristics  Insufficient energy intake  Inadequate food and nutrient intake or assimilation: recent intake compared to estimated requirements  Weight loss  Loss of muscle mass  Wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, thigh and calf 6

7. Adult Malnutrition: Identify ≥ 2 of 6 Characteristics  Loss of subcutaneous fat  Orbital, triceps, fat overlying the ribs  Localized or generalized fluid accumulation that may sometimes mask weight loss  Diminished functional status as measured by hand grip strength 7

8. Figure 1. Hypothetical relationship of Starvation-related Malnutrition (top graph) and Disease- related Malnutrition (bottom graph) assuming the inflammatory condition is relatively constant with changes in lean body mass. Jensen G L et al. JPEN J Parenter Enteral Nutr 2010;34:156-159 Copyright © by The American Society for Parenteral and Enteral Nutrition

9. 9 Figure. Etiology-Based Malnutrition Definitions. Adapted with permission from reference (8): Jensen GL et al. Malnutrition syndromes: A conundrum vs. continuum. JPEN J Parenter Enteral Nutr. 2009;33(6):710-716.

10. Characteristics Recommended for the Diagnosis of Adult Malnutrition  Insufficient energy intake  Weight loss  Loss of muscle mass  Loss of subcutaneous fat  Localized or generalized fluid accumulation that may sometimes mask weight loss  Diminished functional status as measured by handgrip strength White JV, et al. JPEN J Parenter Enteral Nutr. 2012;36:275-283

11.  distinguish between severe and nonsevere malnutrition.  continuous rather than discrete variables  should be routinely assessed on admission and at frequent intervals throughout the patient’s stay in an acute, chronic, or transitional care setting.  standardize the clinician’s approach to the diagnosis and documentation of the presence or absence of adult malnutrition. Characteristics Recommended for the Diagnosis of Adult Malnutrition

12. Table 1. Academy/A.S.P.E.N. Clinical Characteristics That the Clinician Can Obtain and Document to Support a Diagnosis of Malnutrition Malnutrition in the Context of Acute Illness or Injury Malnutrition in the Context of Chronic Illness Malnutrition in the Context of Social or Environmental Circumstances Clinical Characteristic Nonsevere (Moderate) Malnutrition Severe Malnutrition Nonsevere (Moderate) Malnutrition Severe Malnutrition Nonsevere (Moderate) Malnutrition Severe Malnutrition (1) Energy intake Malnutrition is the result of inadequate food and nutrient intake or assimilation; thus, recent intake compared with estimated requirements is a primary criterion <75% of estimated energy requirement for >7 days ≤50% of estimated energy requirement for ≥5 days <75% of estimated energy requirement for ≥ 1 month <75% of estimated energy requirement for ≥ 1 month <75% of estimated energy requirement for ≥3 months ≤50% of estimated energy requirement for ≥3 month White JV, et al. JPEN J Parenter Enteral Nutr. 2012;36:275-283

13. Objectives  Identify proposed etiology based adult malnutrition definitions.  Using the AND evidence analysis library, state best practices for enteral and parenteral nutrition, including permissive underfeeding, BG control, GI complications (aspiration, delayed gastric emptying, diarrhea), administration protocol.

14. Critical Illness Guidelines 2012: Enteral Nutrition vs Parenteral Nutrition  If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus) then recommend EN over parenteral nutrition (PN) for the critically ill adult patient  less septic morbidity and fewer infectious complications (Grade I-strong)  significant cost savings (Grade II-fair) 14 http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

15.  limited evidence that early EN vs. PN decreases hospital length of stay (LOS)  Grade II (fair)  EN vs. PN impact on mortality has not been demonstrated  Grade II (fair) 15 http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1 Critical Illness Guidelines 2012: Enteral Nutrition vs Parenteral Nutrition

16.  Recommend EN be started within 24 to 48 hours following injury or admission to intensive care unit  If EN is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus)  Early EN (EEN) is associated with a reduction in infectious complications in critically ill, adult patients: Grade I (good)  impact of EEN on mortality and length of stay (LOS) is unclear: Grade II (fair) 16 Critical Illness Guidelines 2012: Initiation of Enteral Nutrition http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

17.  Small bowel placement vs gastric placement  Benefits NOT demonstrated include  ensuring adequacy of nutrient delivery  reducing costs of medical care  days on mechanical ventilation  mortality 17 Critical Illness Guidelines 2012: Feeding Tube Placement http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

18.  If a critically ill adult patient is mechanically ventilated and requires EN  recommend small bowel feeding tube placement as studies suggest reduced ventilator-associated pneumonia (VAP) 18 Critical Illness Guidelines 2012: Feeding Tube Placement http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

19. 19 Critical Illness Nutrition Evidence Analysis Project, 2006: Postpyloric vs Gastric  Reduced residual volume  Grade I: good  Reduced aspiration pneumonia  Grade III: limited  Small bowel feeding tube may be useful in pts with supine positioning, sedation and/or large gastric residual volumes  Grade IV: expert opinion  Reduced mortality, LOS, and cost  Grade V: not assignable http://www.adaevidencelibrary.com/topic.cfm?cat=1035

20.  Actual delivery of >60% of EN goal within the first week of hospitalization is associated with fewer infectious complications in critically ill adult patients  Grade II (fair)  Impact on mortality, hospital length of stay (LOS), and days on mechanical ventilation is unclear due to inconsistent results 20 Critical Illness Guidelines 2012: Enteral Nutrition Energy Delivery http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

21. 21 Enteral Feeding Interruption Factors  Mechanical Complications  Feeding-tube displacement, extubation, occlusion  GI complications  Abdominal distention  Delayed gastric emptying  Diarrhea  Ileus  vomiting Supp.Line 1996;28:14

22. 22 Enteral Feeding Interruption Factors  Therapies/ Interventions  Airway management  Bedside procedures  Diagnostic procedures  Medication administra-tion via feeding tube  Physical therapy  Radiologic studies  Surgery  Miscellaneous  Agitation  Coughing or choking  Nursing limitations  Pulmonary aspiration  Slow initiation of feedings Supp.Line 1996;28:14

23. 23 Who Is at Risk for Aspiration?  Pts with trouble swallowing:  Stroke  Confused or debilitated adults  Comatose  Pts with tracheostomies  Pts tracheally intubated  Vagal disruption; trauma  History of aspiration  Severe gastroesophageal reflux

24. 24 Who Is at Risk for Aspiration?  Pts with large bore feeding or suction tubes  Use < 10 F to avoid compromise of LES  Gastric outlet obstruction  Gastroparesis  Postpyloric feeding ?? or jejunostomy  Grade I for decreased residual volume (2006)  Patient position restrictions  supine versus semirecumbent

25.  recommend that critically ill adult patients be positioned in a 30 to 45 degree head of bed elevation, if not contraindicated  during feed and 30 – 60 min after with bolus feed  Elevating head of bed decreases the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharynx  Grade II (fair) 25 Critical Illness Guidelines 2012: Patient Positioning http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

26. 26 Causes of Delayed Gastric Emptying  Diabetes with neuropathy  Medications, chemotherapy, opiods  Gastritis  Paralytic ileus  Formula  Very cold formula  initial use of fiber-supplemented formula  high-fat formula  Head injury/increased intracranial pressure  Mechanical obstruction  Sepsis  Aging gut

27. 27 Check Residuals  Gastric  Check every 4 – 8 hrs  If > 500 ml (ASPEN guidelines) hold feeds for 1 hr and restart at last tolerated rate If low flow rate/hr then residuals should be approx < ½ the flow rate  Small bowel: Usually do not check  Difficult to aspirate contents from small bore tube  If gastric residuals then tube has likely slipped back into the stomach

28. 28 Critical Illness Guidelines 2012: Gastric Residual Volume  Optimizing EN Delivery:  Aspirate gastric residuals < 500 mL per ASPEN Guidelines When no overt signs of intolerance, N,V, abdominal distention present Focus on serial trends not single measurement holding EN when GRV < 500 ml = delivery of less EN GRV does not correlate with risk for aspiration http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

29. Critical Illness Guidelines 2012: Use of Promotility Agent  recommend the use of promotility agents  if the critically ill adult patient has gastroparesis or gastric residual volumes (GRVs) ranging from 200 to 500ml  If there are no contraindications  use of a promotility agent, e.g., metoclopramide, has been associated with increased gastric emptying, improved EN delivery and possibly reduced risk of aspiration. Grade II (fair) 29

30. 30 Critical Illness Guidelines 2012: Blue Dye Use in Enteral Nutrition  recommend against adding blue dye to EN for detection of aspiration in critically ill adult patients  the risk of using blue dye outweighs any perceived benefit  increases mortality risk Grade III (limited)  presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration Grade III (limited) http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

31. 31 JPEN 2002;26:S34-S42

32. 32 JPEN 2002;26:S34-S42

33. 33

34. Critical Illness Guidelines 2012: Fiber  Diarrhea may be reduced in adult critically ill patients when guar gum is included in the EN regimen  The impact of other types of fiber on reducing diarrhea is unclear due to variations in the fiber combinations and amounts used in the studies. 34 http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3222&auth=1

35.  Hypocaloric, high protein feedings for obese, critically ill adults  < 20 kcal per kg adjusted body weight and 2 g protein per kg IBW  promoted shorter intensive care unit (ICU) stays, although total hospital length of stay (LOS) did not differ Nitrogen balance was not adversely affected. Grade III (limited)  effect on infectious complications, days on mechanical ventilation, mortality and cost of care is unsubstantiated Grade III (limited) Critical Illness Guidelines 2012: Hypocaloric, High Protein Feeding Regimen

36.  immune-modulating enteral formulas contain some combination of arginine, glutamine, nucleotides, antioxidants and fish oil  Crucial, Impact, Optimental, Pivot 1.5  carefully evaluate for ICU patients without acute respiratory distress syndrome (ARDS), acute lung injury or severe sepsis  some primary studies and meta-analyses with critically ill populations have shown benefits in reducing infectious complications; Grade III (limited) hospital length of stay; Grade II (fair) Critical Illness Guidelines 2012: Immune-Modulating Enteral Nutrition http://www.adaevidencelibrary.com/topic.cfm?cat=1035

37.  IMF are not associated with  reducing cost of medical care in critically ill Grade III (limited)  Reducing days on mechanical ventilation in critically ill Grade II (fair)  IMF may be associated with increased mortality in severely ill Adequately powered trials not conducted no effect on less severely ill Grade II (fair) http://www.adaevidencelibrary.com/topic.cfm?cat=1035 Critical Illness Guidelines 2012: Immune-Modulating Enteral Nutrition

38. 38 Bolus Feed  Simple, low cost  Schedule feedings according to typical meal patterns  4 - 6 feedings/day administered for 30 – 60 min  Start with ½ to 1 can per feeding  Typical feed is 240 – 480 ml/feeding  2000 ml = 330 ml/feeding 6  2000 ml = 500 ml/feeding 4

39. 39 Continuous Drip Feeding Flow Rates  20 - 30 ml/hr in first 8 – 12 hrs for adults  Advance 10 – 20 ml every 4 – 8 hr until final rate achieved  Final flow rate  divide total daily volume by hours/day  Total volume: 2000 kcal = 2000 ml total volume 1 kcal/ml formula 2000 ml = 83 ml/hr flow rate 24 hrs 2000 kcal = 1667 ml total volume 1.2 kcal/ml formula 1667 ml = 70 ml/hr flow rate 24 hrs

40. 40 Continuous Drip Feeding Flow Rates  Small bowel continuous feeding  Begin at 10 – 25 ml/hr  Advance by 10 – 15 ml increments every 8 – 12 hours

41. 41 Enteral Feeding Interruption Factors  How to determine goal rate compliance?  What to do if there is a compliance problem? 2000 kcal = 2000 ml total volume 1 kcal/ml formula 2000 ml = 83 ml/hr flow rate 24 hrs 2000 ml = 90 ml/hr flow rate 22 hrs 2000 ml = 100 ml/hr flow rate 20 hrs