Choice and Care of Nutritional Access Site

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Choice and Care of Nutritional Access Site

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Nutrition Support Team

• Physicians
• Clinical pharmacists
• Nurse-Clinicians
• Dietitians
• Laboratory research technician
• Ward nursing staff
• In SKH??,????,????,???,???

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Clinical decision algorithm route of nutrition
support
Nutrition Assessment
Decision to institute special nutrition support
YES
NO
Functional GI Tract
Enteral Nutrition
Parenteral Nutrition
Short-term NG, ND,NJ
Long-term Gastrostomy Jejunostomy
Long-term or Fluid restricted
Short-term
GI function
TPN
PPN
Normal
Compromised
GI function return
Intact Nutrients
Defined Formula
Adequate
Inadequate
Adequate
NO
YES
PN
Oral Feeding
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Source of Nutrition

• Enteral nutrition (EN)
• Per oral
• Short-term feeding tubes
• Long-term feeding tubes
• Parenteral nutrition (PN)
• Central parenteral nutrition (CPNTPN)
• Peripheral parenteral nutrition (PPN)
• Long-term home parenteral nutrition (HPN)

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Questions, asked for EN

• How long will feeding be required?
• Can the patient tolerate gastric feeding or is
  postpyloric (or ideally, post-ligament of Treitz)
  access required?
• Who is available with the expertise to place the
  access device (i.e., nurse, surgeon, endoscopist,
  or radiologist)?

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Selections for EN route

• Short-term feeding tubes (lt3 weeks)
• Nasogastric or orogastric, nasoenteric or
  oroenteric
• Gastrostomy, jejunostomy (standard), needle
  catheter jejunostomy (NCJ), nasoenteric tube
  placed during surgery
• Long-term feeding tubes (gt3 weeks)
• Percutaneous endoscopic gastrostomy (PEG),
  percutaneous endoscopic jejunostomy (PEJ)
• Gastrostomy, transgastric jejunostomy,
  jejunostomy

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Pre- vs. Post-pyloric tubes

• Pre-pyloric
• Easier to insert
• More physiologic manner into the stomach
• Less-expensive formulas
• Not require infusion pump

• Post-pyloric
• Prevent TFRA (tube feeding-related aspiration) in
  patients with severe GERD and delayed gastric
  emptying
• Optimal postpyloric tube placement is the 4th
  portion of duodenum or past the ligament of
  Treitz

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Short-term Nonsurgical Prepyloric Tubes

• Nasogastric tubes
• Pros.
• Multi-functions of feeding, decompression,
  delivery of drug, measurement of gastric pH or
  residuals
• generally easy in placement and replacement
• Cons.
• Contraindication severe coagulopathy, nasal and
  facial fractures, or esophageal obstruction
• Orogastric tubes
• Pros. Used in
• Conditions not allowing nasal approach (i.e.,
  nasal or facial trauma, head injury, sinusitis)
• who are sedated, paralyzed, or mechanically
  ventilated
• Cons.
• Not tolerated for prolonged periods in alert
  patients
• tubes may be damaged by teeth

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Short-term Nonsurgical Postpyloric Tubes

• Nasoenteric (ND or NJ)
• Pros.
• Used in patients at high risk of aspiration,
  esophageal reflux, or delayed gastric emptying
• Cons.
• Difficult approach pH sensors, pharmacologic
  measures (Primperan, 15 min before insertion, or
  Erythromycin), fluoroscopy, endoscopy with right
  lateral decubitus position
• Infusion pumps are usually required for
  continuous feeding
• Small caliber preclude delivering most medications

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ND or NJ intubation?

• Should stress ulcer prophylaxis in ND or NJ
  intubation be used?
• 23 patients with ND feeding versus 75 patients
  with NG feeding to have gastric pH gt 5
• Pancreatitis
• NJ feeding within 48 hours of the onset of severe
  acute pancreatitis diminishes endotoxic exposure,
  diminishes the cytokine and systemic inflammatory
  responses, avoids antioxidant consumption and
  does not cause the radiological appearances of
  the pancreas to deteriorate.

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Advances in NG or NE intubation

• Stiff No. 14 to 16 French tubes made from
  polyethylene, PVC, or silicone (less damaging to
  the GI mucosa)
• Small bore tubes, No. 8 to 10 French, are better
  tolerated, easier to pass into the duodenum, low
  incidence of complication
• Stylet to keep rigid, mercury or tungsten at tip
  to add weight

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Potential Complication of Nasogastric and
Nasoenteric Tubes

• Clogging
• Esophageal perforation
• Nasal mucosal ulceration
• Pneumothorax
• Pulmonary intubation

• Epitaxis
• Gastrointestinal bleeding
• Otitis media
• Pulmonary aspiration
• Pyriform sinus perforation

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Gastrostomy

• Created in laparotomy, endoscopy or radiography
• Indication
• head, facial, neck, or esophageal injury
• prolonged neurologic impairment
• repeated aspirations

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Surgical Gastrostomy

• More expensive
• Require general or local anesthesia
• Complication rate up to 15 mortality rate up
  to 6
• Complication
• stoma stenosis and leakage
• wound dehiscence, hemorrhage, and abscess
• skin irritation and cellulitis
• Dislodgement (peritonitis, gastric outlet
  obstruction)

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Percutaneous Endoscopic Gastrostomy

• High Success rate up to 90 Less cost
• Prophylactic Antibiotics use
• Performed at bedside of patients on MV or other
  life-support systems
• Short operative time and require minimal or no
  sedation
• Tract between the skin and the stomach is small
• Feeding can be started soon after insertion (6-24
  hours)
• Removal of the feeding tube is easy and no
  leading to gastrocutaneous fistula

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Percutaneous Endoscopic Gastrostomy

• Contraindication
• Upper mechanical obstruction (e.g., esophageal
  stenosis)
• Obesity
• Coagulopathy
• Ascites
• Intraabdominal infection
• Complication (up to 10) similar to those for
  surgical gastrostomy

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Additional Shortcomings of PEG

• Semi-blind technique, requiring a skilled
  operator
• Pneumoperitoneum may occur but require no
  treatment
• Failure of adhesion between the gastric serosa
  and the abdominal wall may lead to mortality

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Jejunostomy

• Created in laparotomy, endoscopy or radiography
• Indication
• severe GERD
• gastroparesis
• insufficient stomach remnant because of previous
  resection
• post-OP feeding after major surgery
• feeding access for unresectable gastric or
  pancreatic cancers
• Pros.
• Decreased the risk of TFRA
• Early post-OP feeding is possible

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Clinical decision algorithm route of nutrition
support
Nutrition Assessment
Decision to institute special nutrition support
YES
NO
Functional GI Tract
Enteral Nutrition
Parenteral Nutrition
Short-term NG, ND,NJ
Long-term Gastrostomy Jejunostomy
Long-term or Fluid restricted
Short-term
GI function
TPN
PPN
Normal
Compromised
GI function return
Intact Nutrients
Defined Formula
Adequate
Inadequate
Adequate
NO
YES
PN
Oral Feeding
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Parenteral nutrition

• Peripheral parenteral nutrition (PPN)
• Central parenteral nutrition (CPNTPN)
• Long-term home parenteral nutrition (HPN)

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Questions, asked for PN

• Does the GI tract function preserve?
• How long will PN be required?
• Which route of access is favored for the
  patients specific condition?
• Does the patient have risk factors of any
  complication resulted from starting PN?

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PPN

• High risk of thrombophlebitis
• Low Osmolarity less than 600-900 mOsm/kg
• Short-term up to 2 weeks
• Not the optimal choice for
• significant malnutrition
• severe metabolic stress
• large nutrient or electrolyte needs (especially
  potassium, a strong vascular irritant)
• fluid restriction
• the need for prolonged intravenous nutrition
  support

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Considerations of TPN

• Impossibility for enteral nutrition
• Inadequacy for enteral nutrition
• Increment of the severity of disease by enteral
  nutrition
• PLUS
• Anticipated to have PN for more than 7 days

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Indications of TPN

• Acute pancreatitis
• Intestinal disease (IBD, NEC, radiation colitis,
  ileus, intractable diarrhea / vomiting)
• Cancer, responsive to C/T and R/T
• Hepatic failure
• Renal failure
• Short bowel syndrome
• Enterocutaneous fistula
• Perioperative support

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Central Venous Access

• Routes for access
• Antecubital approach
• Internal jugular vein approach
• External jugular vein approach
• Subclavian vein approach
• Femoral vein approach
• Methods
• Percutaneous approach
• Cut down
• Tunneled

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Antecubital approach

• Success rate 40-70
• Limited use by lack of surface anatomy in obese
  and edematous patients
• Specific complication sterile phlebitis, limb
  edema, pericardial tamponade (greater catheter
  tip migration occurring with arm movements)

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Internal jugular vein approach

• Success rate gt 90 (operator independent)
• Specific Complication ICA puncture (80-90),
  pneumothorax, vessel erosion

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External jugular vein approach

• Success rate 75-95
• Advantage part of the surface anatomy,
  cannulated in clotting abnormalities,
  pneumothorax is avoid
• Alternative to IJV in selected patients with
  clotting abnormalities or those with severe lung
  disease or on high-level PEEP
• Specific Complication rare, mainly associated
  with catheter maintenance rather than
  venipuncture

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Subclavian vein approach

• Success rate 90-95 (operator dependent)
• Most comfortable
• Specific complication pneumothorax (1-5,
  operator dependent), arterial puncture

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Femoral vein approach

• Success rate 90-95
• Most difficult in care
• Specific complication arterial puncture, deep
  venous thrombosis
• No higher incidence of infection thromboembolism
  is not as clinically significant as once believed

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Mechanical complications

• Pneumothorax
• Brachial plexus injury
• Subclavian and carotid artery puncture
• Hemothorax
• Thoracic duct injury
• Chylothorax
• Cardiac perforation
• Catheter malposition

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Catheter-induced Thrombosis

• Secondary to injury to the vein wall during
  insertion
• Chemically induced thrombosis (osmolarity of
  infusate)
• Malposition of catheter tips into the arm veins
  or small veins of the neck or chest
• Materials of CVC silicone appears less
  thrombogenicity
• 6 of thrombosis leads to complete occlusion

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Hint of Formation of Thrombosis and Occlusion

• Arm and neck pain or swelling
• Venous distension on chest wall or neck
• Symptoms of pulmonary embolism
• Poor catheter function

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Catheter-related Infection

• Definition
• gt 15 colony-forming units by semiquantitative
  culture method (if lt 15 CFUs, contamination is
  considered)
• Local or exit-site infection (erythema,
  cellulitis, or purulence)
• Catheter-related bacteremia (systemic blood
  cultures positive for identical organism on
  catheter segment and no other sources)
• Catheter-related sepsis or septic shock

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Hints of CRI

• Fever (up to 38?C, 2 times, every 4 hours)
• Chills
• Abrupt increase of blood sugar
• Hypotension
• Tachycardia
• Leukocytosis

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Epidemiology of CRI

• Staphylococcus aureus, Staphylococcus
  epidermidis, Candida albicans (for diabetic with
  prolonged CVC on broad-spectrum antibiotics)
  GNB
• CRI rate 2.8-27
• Mortality rate 14-28
• Origins of CRI
• contamination during insertion
• skin insertion site
• the catheter hub
• hematogenous seeding
• infusate contamination

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Keys to reduce CRI

• Aseptic procedure during insertion
• Nursing care of access site
• Catheter Design Innovations to reduce CRI
• Antimicrobial cuffs
• Antibiotics, bonding to CVC
• Long-acting skin cleansing agents

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Management of suspected CRI
1

• Initial evaluation
• Evaluate catheter insertion site and culture any
  drainage
• Obtain blood cultures from peripheral vein and
  central vein catheter
• Consider culture of hub, skin, infusate
• Culture catheter tip, if removed
• CBC/DC
• Look for other sources of infection
• Stop TPN for 48-72 hours

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Management of suspected CRI
2

• Indications for CVC removal
• Immediate removal
• Purulent discharge or abscess at insertion site
• Septic shock without other sources of infection
• Removal of replaceable catheters after obtaining
  culture results
• Persistent or recurrent catheter related
  bacteremia
• Candida species or Pseudomonas infection
• Polymicrobial infection
• Staphylococcus aureus infection

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Management of suspected CRI
3

• Antibiotic therapy
• Empiric antibiotics administered through CVC
  until culture results are back
• Specific antibiotics administered through CVC
  once culture results are available
• Repeat blood culture in 48 and 72-96 hours to
  ensure clearance of bacteremia
• Fever should resolve within 72-96 hours if
  appropriate antibiotics are given remove
  catheter if fever persists

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? ? ? ?
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1.??PPN???, ???????

• PPN Partial parenteral nutrition
• ???????2??
• ????significant malnutrition, severe metabolic
  stress?fluid restriction???
• ???thrombophlebitis
• ????????

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2.??TPN????, ???????

• Anticipated to have parenteral nutrition for more
  than 7 days
• Elderly patients with decreased oral intake
  secondary to dysphagia
• Severely malnourished patients requiring surgery
• Malignance, responsive to radiation therapy or
  chemotherapy
• Severe, active Crohns disease with malabsorption

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3.??TPN?central venous catheter (CVC)?vascular
access, ???????

• ???route?subclavian vein, internal jugular vein
  and femoral vein
• ?????????percutaneous approach, cut down?tunneled
• ??catheter????????pneumothorax, hemorrhage and
  catheter malposition
• ??subclavian vein??catheter, ?????pneumothorax,
  ?????????????
• Tunneled CVC?non-tunneled CVC???????

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4.????????????, ???????

• To prepare skin with disinfectant by circular
  motion from insertion site to periphery
• Even during catheter insertion the contact of the
  gloves with the skin should be minimized to
  reduce bacterial contamination
• Careful suturing or subcutaneous tunneling is
  essential to minimize catheter motion at the site
  of insertion
• Apply occlusive gauze dressing or semi-permeable
  transparent dressing
• Can infuse drug and take blood sample in the same
  lumen of the catheter

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5.??Catheter related infection (CRI), ???????

• ???????Staphylococcus aureus?Staphylococcus
  epidermidis
• Candida species ????diabetic patient with
  prolonged catheterization on broad-spectrum
  antibiotics
• ?tip culture????????????15 colony-forming units
  (CFUs), ???????????????
• Skin site with erythema, cellulites or purulence
  ???CRI
• ?????CRI, ??CVC?, ???tip culture

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6.??Management of the febrile patient with
central venous catheter, ???????

• Removal of the catheter in every febrile patient
  is indicated.
• In a stable febrile patient with no obvious
  source of fever, indications for CVP should be
  reviewed and the catheter withdrawn if it is no
  longer required
• For patients with excessive risks for new
  catheter placement, guide wire exchange of the
  catheter is justifiable after obtaining blood
  cultures and tip culture of old catheter
• When catheter-related bacteremia does develop,
  antibiotic therapy is necessary
• ????????

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7.??Parenteral nutrition?Enteral nutrition???,
???????

• ??intractable nausea or vomiting, persistent
  diarrhea, mechanical obstruction?severe
  malabsorption???, ???parenteral nutrition
• Parenteral nutrition???Dextrose, Amino acid?Lipid
  emulsion, ???????, ???????enteral feeding
• Dextrose???3.4 Kcal/g, 10 Intralipid???1.1
  Kcal/mL, 20 Lipofundin???2 Kcal/mL???
• Enteral nutrition???????, ???????????????????
• ??????????, ????enteral nutrition???,
  ???percutaneous endoscopic gastrostomy (PEG)

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8.??PEG???, ???????

• ????long-term access, easily cared for,
  replaceable
• ??coagulopathy, ascites?intra-abdominal
  infection???, ????PEG
• ?????stoma stenosis and leakage, wound infection,
  bleeding?dislodgement
• ?surgical gastrostomy??, PEG?????
• ???PEG???????????????

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9.??Enteral routes of nutritional access???,
???????

• NG intubation????????GERD, aspiration, esophageal
  stricture, perforation and oropharyngeal mucosal
  injury
• NG tube?, Silicone????????????????, ???????????
• ??Gastric outlet obstruction?duodenal
  obstruction???, ???gastrostomy
• ??acute pancreatitis???, ??NJ tube?NG tube??????
• ???Primperan?Erythromycin????NJ tube????

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10.?????Nutrition Support Team, ??????

• Physician
• Pharmacist
• Nurse-Clinician
• Dietician
• ????

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Choice and Care of Nutritional Access Site

• ??? ??