Chapter 073. Enteral and Parenteral Nutrition (Part 4) pdf

Chapter 073. Enteral and
Parenteral Nutrition
(Part 4)

Although PN was initially relatively expensive, its components are often
less expensive than specialty enteral formulas. Percutaneous placement of a
central venous catheter into the subclavian or internal jugular vein with
advancement into the superior vena cava can be accomplished at the bedside by
trained personnel using sterile techniques. Peripherally inserted central catheters
can also be placed within the lumen in the central vein, but this technique is
usually more appropriate for non-ICU patients. The subclavian or internal jugular
lines can be changed over a wire, but this carries a greater risk of pneumothorax or
serious vascular damage. The peripherally inserted catheters are subject to
position-related flow, and the catheter cannot be changed over a wire. Inserting a
nasogastric tube is a bedside procedure, but many critically ill patients have
impaired gastric emptying that increases the risk of aspiration pneumonia. This
risk can be reduced by feeding directly into the jejunum beyond the ligament of
Treitz. This usually requires fluoroscopic guidance or endoscopic placement. In
patients who have planned laparotomies or other conditions likely to require a
prolonged need for SNS, it is advantageous to place a jejunal feeding tube at the
time of surgery.
Although most SNS is delivered in hospitals, some patients require it on a
long-term basis. If they have a safe environment and a willingness to learn the
self-care techniques, SNS can be administered at home. The clinical outcomes of
patients with severe intestinal disorders treated with home PN or EN are
summarized in Table 73-2. PN infused at home is usually cycled overnight to give
greater daytime freedom. Other important considerations in determining the
appropriateness of home PN or EN are that the patient's prognosis is longer than
several months and that the therapy benefits quality of life.
Table 73-2 Summary of Outcomes for Patients on Home Parenteral
and Enteral Nutrition (HPEN)

Therapy
Status, % at 1
year
b

Rehabi
litation
c

Status, % in
Complic
ations
d
per
Patient-Year
1st year


Di
agnosis
N
umber
in
Group

ge in
Year
s

Surv
ival
a

on
Ther
apy
ull
Oral
Nutr
ition

C
ontinue
d on
HPEN
Rx
ied
H
PEN
N
onHPE
N
Home Parenteral Nutrition
Cr
ohn's
disease
5
62 6 6 0

2
5 0 8
0
.9
1.
1
Isc
hemic
3
31 9 7 7
4
8 9 3 1
1
.4
1.
1
bowel
disease
M
otility
disorder
2
99 5 7 1
4
4 1 9 9 2
1
.3
1.
1
Co

ngenital
bowel
defect
1
72 4 2
4
7 3 7 1
2
.1
1.
0
Hy
peremesis
gravidaru
m
1
12 8 00 00
0

3 6
1
.5
3.
5
Ch
ronic
pancreatit
is
1
56 2 0 2

1
0 0 8
1
.2
2.
5
Ra
diation
enteritis
1
45 8 7 8
4
9 2 2 9
0
.8
1.
1
Ch
ronic
adhesive
obstructio
ns
1
20 3 3 7
3
4 3 3 8 0
1
.7
1.
4

Cy
stic
fibrosis
5
1 7 0 8
1
3 6 4 6 6
0
.8
3.
7
Ca
ncer
2
122 4 0 6
8

3 9 7 4
1
.1
3.
3
AI
DS
2
80 3 0 3
6

3 3 9
1

.6
3.
3
Home Enteral Nutrition
Ne
urologic
disorders
of
swallowi
ng
1
134 5 5 9
2
5 8 4 1
0
.3
0.
9
Ca
ncer
1
644 1 0 0
6

9 1 9 1
0
.4
2.
7
a

Survival rates on therapy are values at 1 year, calculated by the life table
method. This will differ from the percentage listed as died under Therapy Status,
since all patients with known end points are considered in this latter measure. The
ratio of observed versus expected deaths is equivalent to a Standard Mortality
Ratio.
b
Not shown are those patients who were back in hospital or who had
changed therapy type by 12 months.
c
Rehabilitation is designated complete (C), partial (P), or minimal (M),
relative to the patient's ability to sustain normal age-related activity.
d
Complications refer only to those complications that resulted in
rehospitalization.
Source: Derived from North American HPEN Registry.
Table taken from previous chapter by Lyn Howard, MD.