STUDY - Technical - New Dacian's Medicine
Parenteral
and Enteral Nutritional Therapy (1)
Translation Draft
Parenteral and enteral nutrition ensures the maintenance of vital functions in patients who cannot properly feed themselves orally and who are subject to the debilitating effects of malnutrition. These include susceptibility to infections and the consequences of prolonged immobilisation (pulmonary embolism, aspiration pneumonia, decubit escare, all delaying recovery and contributing to increased mortality).
The term enteral means intestinal feeding and therefore includes normal nutrition in the present context, however, involves the administration of standard food by means of a tube inserted into the upper gastrointestinal tract. Parenteral means the administration of nutritional principles through infusions, directly into the bloodstream. Although these two feeding methods are different, their purpose is identical. If possible, enteral nutrition is preferred, as it supports gastrointestinal functions (both digestive and absorption) and the advantage of having an immunological barrier is maintained. The cost of this process is ten times lower than that of parenteral nutrition.
In the 1960s, it became possible to develop complete nutrition (energy, amino acids, minerals and vitamins) achieved in the long term by means of an infusion mounted in a central vein. Such therapy leads to the restoration of homeostasis in casec patients and promotes wound healing in adults and the normal growth and development of children. Total parenteral nutrition is available in large hospitals and in some cases at home. The improvement of hypercaloric isotone lipid solutions made it possible to provide caloric requirements and other essential nutritional compounds on the peripheral venous pathway. However, peripheral veins cannot be used for a long time for nutritional infusions, their long-term administration requiring central venous approach.
When will the decision be made on the use of parenteral or enteral nutrition? This decision should be based on the fact that the improvement or recovery of malnutrition will increase the quality of life or the recovery capacity of critically ill patients. Approximately 15-20% of hospitalized patients have signs of malnutrition. Some of them will benefit from dietary therapy, but for others, emaciation is the final stage of an incurable condition.
An objective clinical judgment must distinguish between the two categories: 1. the possible benefits and risks of nutritional therapy must be known, 2. a possibility/way to communicate these benefits and risks to the patient and his family must be found, 3. the legal framework in force must be known. As with resuscitation and life support measures, once initiated, these therapies are difficult to stop.
The first step asks the doctor to outline the nutritional implications in the pathological process. Can the patient's functional status or even treatment harm appetite or food intake and absorption over a longer period of time? Because it is easier to prevent than to treat malnutrition, this first step is mandatory in the initial assessment. The second step is to determine whether the patient is already malnourished, so as to lead to decreased muscle mass or alteration of critical functions, such as healing capacity and pulmonary ventilation.
The presence or absence of metabolic stress should be noted, since the occurrence of wounds or infections may suggest the release of hormonal and cytokine factors that reduce the effectiveness of nutritional therapy. Appreciation of the patient's nutritional status was "discussed" in previous posts. Weight loss unaccompanied by a functional deficit is probably without consequence. Functional damage usually becomes important when more than 20% of the protein mass has been lost and, more likely, if a vital organ is directly affected by the disease.
Once it has been established that the patient is at risk or even suffering from malnutrition, the question is whether artificial nutrition supplementation will have a positive impact on the course of the disease and improve the quality of life. This issue takes into account ethical considerations and risks or possible benefits. While providing food and water is a routine medical issue, eating support, enteral or parenteral, is associated with discomfort and some risks and should only be indicated when the benefits outweigh the risks and always with the patient's consent. If it has been established that the prevention or treatment of malnutrition by specialized nutritional support improves the prognosis and quality of life, dietary requirements and route of administration should be established.
What are the risks and benefits of nutritional support? Mainly, the risks are determined by the way of administering the nutritional principles. Ideally, the nutritional requirements should be ensured by paying particular attention to oral intake, using liquid supplements (if necessary) and monitoring food consumption, including repeated calculation of caloric intake. This is the most effective method, because food assimilation begins with the cephalic phase of digestion (the infants fed on the probe grow better if the cephalic stimulation of digestion is ensured by a pacifier). Anorexia, impaired swallowing or intestinal disorders may limit oral intake, in which case the first option is enteral nutrition.
The intestine and associated digestive organs allow 70% of the necessary nutrients to pass directly from the food into the lumen. In addition, glutamine, short chain fatty acids and nuleotides may be of particular importance in maintaining the integrity of the intestinal mucosa. Enteral nutrition also supports intestinal functions by stimulating blood flow in the splanhnic territory, neuronal activity, the release of IgA antibodies and by secretion of gastrointestinal hormones, such as epidermal growth factor with role in the trophic activity of the intestine. All these factors support the immunological barrier at the intestinal level, preventing the invasion of intestinal flora microorganisms throughout the body.
For all these effects on intestinal functions, it is good to use enteral nutrition, even when parenteral nutrition is required. In the past, intestinal rest was considered to be the key to success in the treatment of severe gastrointestinal disorders. Today, total rest of the intestine is rarely indicated. Parenteral nutrition is still the only therapeutic alternative in the early stages of short bowel syndrome, in severe hemorrhagic pancreatitis, necrotizing enterocolitis, prolonged ileus and distal bowel obstruction.
Specialized nutritional support is expensive, reaching up to 1% of the health budget in most developed countries. Essential parameters, such as mortality rates, incidence of major complications and duration of hospitalization, are taken into account by studies comparing risks and benefits. At the same time, parameters such as improved nitrogen balance, increased serum albumin levels and improved delayed hypersensitivity are no longer accepted.
In the case of perioperative nutrition, if it is known that malnourished patients recover very hard postoperatively, instead it is not known to what extent the preoperative parenteral nutrition applied to them improves the recovery capacity following surgery. However, a synthetic analysis of 18 studies, as well as other studies, found that preoperative parenteral nutrition has a positive effect on severely malnourished patients requiring surgery. In patients undergoing parenteral nutrition the incidence of non-infectious complications (e.g. pulmonary embolism, delayed healing) was decreased in the postoperative period.
When patients experience moderate or moderate malnutrition, the risk of infection through preoperative parenteral nutrition is greater than the benefits. There is a danger of septicaemia and other infectious complications that are not directly related to the central venous line, such as pneumonia or wound infection. Preoperative enteral nutrition, where possible, is safe and cheap, especially if it is provided at home. Immediate postoperative nutritional support is indicated for patients who have received preoperative support and patients who are less likely to resume oral nutrition within 10 days.
Usually, the parenteral pathway is used, due to postoperative ileeus or the risk of dehiscence of intestinal anastomosis. However, prudent jejunal nutrition is equally well tolerated. Supplements with specialized enteral formulas containing a variety of unconditionally essential nutrients can bring benefits, especially in particularly immunodepressed patients under postoperative conditions.
For critical conditions, nutritional support instituted very early (during the first 48 hours) improves survival, reduces infections and the duration of hospitalization in patients with severe abdominal trauma. Enteral therapy, where possible, was found to be superior to parenteral therapy, as several studies have shown. The reasons for this beneficial effect of early enteral nutrition are not yet known (such early therapy has provided comparable benefits to traumatized patients who have not experienced obvious malnutrition. Animal studies suggest that enteral nutrition has the effect of decreasing systemic infections with entero-bacteria and reducing systemic catabolic response).
This phenomenon has not been objectified in humans, but enteral nutrition can prevent excessive bacterial multiplication and decrease the incidence of aspiration pneumonia. Basically, there is a question of obtaining jejunal access to a patient in critical condition, so difficult to transport for intubation under contro, ultrasound or radiological. Sometimes, by nasal or percutaneous route, a tube of jejunal feeding and gastric suction can be fitted to the patient's bed. When the indication of laparotomy appears, a feeding tube may be placed intraoperatively. Most studies of enteral nutrition in critically ill patients have used either a complete polymer formula or one with hydrolysed proteins. Parenteral formulas enriched with large amounts of branched amino acids (AAR) improve the nitrogen balance, but appear to affect clinical recovery.
For neoplastic cheesexia, various early studies have suggested that cancerpatients with cheesexia benefit from parenteral nutrition, but other studies have shown that there are more risks than benefits for patients undergoing chemotherapy or radiotherapy. Neoplastic scans with severe malnutrition who undergo surgery appear to benefit from the preoperative effects of parenteral nutrition, as do other malnourished patients. In two prospective studies, long-term survival was higher in patients receiving bone marrow transplantation associated with parenteral or enteral nutrition in the cytoreductional phase.
Nutritional support did not influence the frequency of initial infectious complications, graft rejection or graft-versus-host disease. Immediate morbidity is reduced if glutamine supplements are associated with parenteral nutrition solution. For neoplastic patients with intratable disease, enteral feeding is usually justified if preferred by the patient and the family. Parenteral nutrition should only be ensured if improvement in clinical status is expected and when the quality of survival at home is predictable.
We still have plenty to present here, but for next time...
Parenteral and enteral nutrition ensures the maintenance of vital functions in patients who cannot properly feed themselves orally and who are subject to the debilitating effects of malnutrition. These include susceptibility to infections and the consequences of prolonged immobilisation (pulmonary embolism, aspiration pneumonia, decubit escare, all delaying recovery and contributing to increased mortality).
The term enteral means intestinal feeding and therefore includes normal nutrition in the present context, however, involves the administration of standard food by means of a tube inserted into the upper gastrointestinal tract. Parenteral means the administration of nutritional principles through infusions, directly into the bloodstream. Although these two feeding methods are different, their purpose is identical. If possible, enteral nutrition is preferred, as it supports gastrointestinal functions (both digestive and absorption) and the advantage of having an immunological barrier is maintained. The cost of this process is ten times lower than that of parenteral nutrition.
In the 1960s, it became possible to develop complete nutrition (energy, amino acids, minerals and vitamins) achieved in the long term by means of an infusion mounted in a central vein. Such therapy leads to the restoration of homeostasis in casec patients and promotes wound healing in adults and the normal growth and development of children. Total parenteral nutrition is available in large hospitals and in some cases at home. The improvement of hypercaloric isotone lipid solutions made it possible to provide caloric requirements and other essential nutritional compounds on the peripheral venous pathway. However, peripheral veins cannot be used for a long time for nutritional infusions, their long-term administration requiring central venous approach.
When will the decision be made on the use of parenteral or enteral nutrition? This decision should be based on the fact that the improvement or recovery of malnutrition will increase the quality of life or the recovery capacity of critically ill patients. Approximately 15-20% of hospitalized patients have signs of malnutrition. Some of them will benefit from dietary therapy, but for others, emaciation is the final stage of an incurable condition.
An objective clinical judgment must distinguish between the two categories: 1. the possible benefits and risks of nutritional therapy must be known, 2. a possibility/way to communicate these benefits and risks to the patient and his family must be found, 3. the legal framework in force must be known. As with resuscitation and life support measures, once initiated, these therapies are difficult to stop.
The first step asks the doctor to outline the nutritional implications in the pathological process. Can the patient's functional status or even treatment harm appetite or food intake and absorption over a longer period of time? Because it is easier to prevent than to treat malnutrition, this first step is mandatory in the initial assessment. The second step is to determine whether the patient is already malnourished, so as to lead to decreased muscle mass or alteration of critical functions, such as healing capacity and pulmonary ventilation.
The presence or absence of metabolic stress should be noted, since the occurrence of wounds or infections may suggest the release of hormonal and cytokine factors that reduce the effectiveness of nutritional therapy. Appreciation of the patient's nutritional status was "discussed" in previous posts. Weight loss unaccompanied by a functional deficit is probably without consequence. Functional damage usually becomes important when more than 20% of the protein mass has been lost and, more likely, if a vital organ is directly affected by the disease.
Once it has been established that the patient is at risk or even suffering from malnutrition, the question is whether artificial nutrition supplementation will have a positive impact on the course of the disease and improve the quality of life. This issue takes into account ethical considerations and risks or possible benefits. While providing food and water is a routine medical issue, eating support, enteral or parenteral, is associated with discomfort and some risks and should only be indicated when the benefits outweigh the risks and always with the patient's consent. If it has been established that the prevention or treatment of malnutrition by specialized nutritional support improves the prognosis and quality of life, dietary requirements and route of administration should be established.
What are the risks and benefits of nutritional support? Mainly, the risks are determined by the way of administering the nutritional principles. Ideally, the nutritional requirements should be ensured by paying particular attention to oral intake, using liquid supplements (if necessary) and monitoring food consumption, including repeated calculation of caloric intake. This is the most effective method, because food assimilation begins with the cephalic phase of digestion (the infants fed on the probe grow better if the cephalic stimulation of digestion is ensured by a pacifier). Anorexia, impaired swallowing or intestinal disorders may limit oral intake, in which case the first option is enteral nutrition.
The intestine and associated digestive organs allow 70% of the necessary nutrients to pass directly from the food into the lumen. In addition, glutamine, short chain fatty acids and nuleotides may be of particular importance in maintaining the integrity of the intestinal mucosa. Enteral nutrition also supports intestinal functions by stimulating blood flow in the splanhnic territory, neuronal activity, the release of IgA antibodies and by secretion of gastrointestinal hormones, such as epidermal growth factor with role in the trophic activity of the intestine. All these factors support the immunological barrier at the intestinal level, preventing the invasion of intestinal flora microorganisms throughout the body.
For all these effects on intestinal functions, it is good to use enteral nutrition, even when parenteral nutrition is required. In the past, intestinal rest was considered to be the key to success in the treatment of severe gastrointestinal disorders. Today, total rest of the intestine is rarely indicated. Parenteral nutrition is still the only therapeutic alternative in the early stages of short bowel syndrome, in severe hemorrhagic pancreatitis, necrotizing enterocolitis, prolonged ileus and distal bowel obstruction.
Specialized nutritional support is expensive, reaching up to 1% of the health budget in most developed countries. Essential parameters, such as mortality rates, incidence of major complications and duration of hospitalization, are taken into account by studies comparing risks and benefits. At the same time, parameters such as improved nitrogen balance, increased serum albumin levels and improved delayed hypersensitivity are no longer accepted.
In the case of perioperative nutrition, if it is known that malnourished patients recover very hard postoperatively, instead it is not known to what extent the preoperative parenteral nutrition applied to them improves the recovery capacity following surgery. However, a synthetic analysis of 18 studies, as well as other studies, found that preoperative parenteral nutrition has a positive effect on severely malnourished patients requiring surgery. In patients undergoing parenteral nutrition the incidence of non-infectious complications (e.g. pulmonary embolism, delayed healing) was decreased in the postoperative period.
When patients experience moderate or moderate malnutrition, the risk of infection through preoperative parenteral nutrition is greater than the benefits. There is a danger of septicaemia and other infectious complications that are not directly related to the central venous line, such as pneumonia or wound infection. Preoperative enteral nutrition, where possible, is safe and cheap, especially if it is provided at home. Immediate postoperative nutritional support is indicated for patients who have received preoperative support and patients who are less likely to resume oral nutrition within 10 days.
Usually, the parenteral pathway is used, due to postoperative ileeus or the risk of dehiscence of intestinal anastomosis. However, prudent jejunal nutrition is equally well tolerated. Supplements with specialized enteral formulas containing a variety of unconditionally essential nutrients can bring benefits, especially in particularly immunodepressed patients under postoperative conditions.
For critical conditions, nutritional support instituted very early (during the first 48 hours) improves survival, reduces infections and the duration of hospitalization in patients with severe abdominal trauma. Enteral therapy, where possible, was found to be superior to parenteral therapy, as several studies have shown. The reasons for this beneficial effect of early enteral nutrition are not yet known (such early therapy has provided comparable benefits to traumatized patients who have not experienced obvious malnutrition. Animal studies suggest that enteral nutrition has the effect of decreasing systemic infections with entero-bacteria and reducing systemic catabolic response).
This phenomenon has not been objectified in humans, but enteral nutrition can prevent excessive bacterial multiplication and decrease the incidence of aspiration pneumonia. Basically, there is a question of obtaining jejunal access to a patient in critical condition, so difficult to transport for intubation under contro, ultrasound or radiological. Sometimes, by nasal or percutaneous route, a tube of jejunal feeding and gastric suction can be fitted to the patient's bed. When the indication of laparotomy appears, a feeding tube may be placed intraoperatively. Most studies of enteral nutrition in critically ill patients have used either a complete polymer formula or one with hydrolysed proteins. Parenteral formulas enriched with large amounts of branched amino acids (AAR) improve the nitrogen balance, but appear to affect clinical recovery.
For neoplastic cheesexia, various early studies have suggested that cancerpatients with cheesexia benefit from parenteral nutrition, but other studies have shown that there are more risks than benefits for patients undergoing chemotherapy or radiotherapy. Neoplastic scans with severe malnutrition who undergo surgery appear to benefit from the preoperative effects of parenteral nutrition, as do other malnourished patients. In two prospective studies, long-term survival was higher in patients receiving bone marrow transplantation associated with parenteral or enteral nutrition in the cytoreductional phase.
Nutritional support did not influence the frequency of initial infectious complications, graft rejection or graft-versus-host disease. Immediate morbidity is reduced if glutamine supplements are associated with parenteral nutrition solution. For neoplastic patients with intratable disease, enteral feeding is usually justified if preferred by the patient and the family. Parenteral nutrition should only be ensured if improvement in clinical status is expected and when the quality of survival at home is predictable.
We still have plenty to present here, but for next time...
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Gratitude (Energy = Knowledge = Understanding = Love x Gratitude
X Gratitude)!!!
Dorin, Merticaru