Benefits of early nutrition within 24-48 hrs (Aspen guidelines)

  • maintain gut integrity - functional integrity maintains tight junctions in intraepithelial cells and stimulated blood flow

  • structural integrity by maintaining villous height and supports IgA producing immunocytes

  • early feeding reduces mortality, infection, and decreases length of stay

Gastric residuals

  • stomach produces approximately 2 Liters per day

  • not recommended to check (does not correlate with incidences of pneumonia, regurgitation or aspiration)

  • does not protect patients from complications (increases tube clogging, delays amount of enteral nutrition given, wasted RN time)

  • if gastric residuals are used:

    • recommended cutoff is 500mL + other signs of intolerance (vomiting, abdominal distension, complaints of discomfort, diarrhea, reduce passage of flatus/stool, abnormal radiographs)​

Vasopressors

  • Attending specific

  • not a lot of research

  • pay attention to tolerance of feeds, lactate, etc. 

TPN vs Enteral Nutrition

  • if the gut works, use it

  • little benefit of TPN in the first week of hospital stay

  • nourished patients have an increased infectious mortality and less likely to be discharged from the hospital alive if TPN started on day 3 vs day 8

  • malnourished patients should start TPN as able if unable to start enteral nutrition

  • goal is to use TPN for 7 days to maximize its benefits

Total Parenteral Nutrition (TPN)

 

TPN should only be considered when nutritional support is indicated but adequate nutrients cannot be delivered through the GI tract. It is not indicated when anticipated use is for < 72 hours.

 

Indications

  • massive small bowel resection (< 100cm of small bowel or 60cm of small bowel with ileal cecal valve and colon

  • chronic malabsorption (from chronic disease or radiation)

  • enterocutaneous fistulas 

    • when bowel rest is indicated for at least 7 days 

    • high output enterocutaneous fistula stimulated by enteral nutrition

  • severe malnutrition (prealbumin<10 with normal CRP)

    • + malabsorption > 7-10 days

    • major GI surgery or post-operative small bowel obstruction present and inability to utilize the GI tract for > 7 days

    • suspected GI ischemia

    • mechanical bowel obstruction with inability to utilize the GI tract for > 7 days

    • prolonged hemodynamic instability precluding the advancement of enteral nutrition due to the use of vasopressors for hypotension for more than 5days

    • enteral feeding access not possible due to one of the following conditions:

      • Obstructing lesions of the aerodigestive tract e.g. pharynx, esophagus

      • Gastric outlet obstruction

      • Tracheo-esophageal fistula

    • upper gastrointestinal hemorrhage where enteral access is not feasible for 5-7 days

    • severe hemorrhagic pancreatitis requiring bowel rest for >7 days. (Defined as three or more of Ranson's early objective signs of severity of acute pancreatitis

Contraindications

  • TPN used for < 7 days due to no clinical benefit

  • poor gastric empty without proper small bowel enteral access

  • short term colonic ileus

Ostomy

  • if producing more than 1200mL/day, need to re-evaluate the kinds of intake the patient is taking (make sure there is no bowel regimen scheduled)

  • use stoma powder

  • bag should be emptied frequently so that it lasts for at least 3 days before needing to change it

  • try to not drink out of a straw because of the gas producing effects

... but I would more especially commend the clinician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.
 
Hippocrates, 400 BC