Artificial Nutrition

 

General:

The term artificial nutrition refers to nutrients that are not given by mouth (orally). The food can be supplied through the gastrointestinal tract (called tube feeding or enteral nutrition) or through the veins (parenteral nutrition). Routes of administration for tube feeding include nasogastric tube, nasoduodenal tube, needle jejunostomy, via a percutaneous endoscopic gastrostomy (PEG) tube or a jejunostomy (PEJ) tube. Routes of administration for parenteral nutrition are: a central venous catheter, implanted port catheter (port-a-cath), A-V shunt, PICC (peripherally inserted central catheter). It is not possible to give patients the correct amount of nutrients through a peripheral route, due to the risk of inflammatory responses from the high osmolar fluids.

 

Oral administration of food is always preferred. The goal is always for ideal nutrition. For patients who are malnourished (based on screening using SNAQ 3 of MUST 2), intervention with artificial nutrition is necessary. If it is expected that food intake during a period of 7 days will be less than 500 kcal per day in a patient with good nutritional status, the food should be supplemented with enteral nutrition. Only in cases where it is not possible to feed the patient best through the enteral route (due to obstruction, severe malabsorption, or short bowel syndrome) is parenteral nutrition the correct option.

 

Determining if artificial nutrition is indicated:

• when there has been unwanted weight loss of > 5% within a 1-month period or > 10% within a 6-month period
• when it is expected that food intake during at least 7 days will contain insufficient protein and calories, in patients who are undernourished
• if the patient cannot or must not in the nutrients optimally by mouth.

 

Multidisciplinary support:

Multidisciplinary teamwork is essential to good nutritional therapy. There are three aspects: a medical (choice of route of administration), nursing (taking care of the route of administration and assessing the administration) and dietetic (determining the nutrient requirements and the best choice of tube feed).

The steps taken in multidisciplinary team discussion:

1. medical grounds for artificial nutrition
2. detecting any nutrient deficiencies in the feeds
3. determining the patient’s nutritional needs
4. determining the type and quantity of nutritional material in the feeds
5. determining the route and method of administration
6. determining whether a progressive feeding regimen is required, and if so, setting it up
7. ensuring continuous feeding
8. if necessary: arranging for artificial nutrition in the home setting
9. evaluating the nutritional therapy in the clinic and at home
10. counseling in the transition from tube feeding to food by mouth
11. preventing and resolving complications

 

The dietician will usually be the clinical coordinator and, in consultation with the doctor and nursing staff, will carry out most of the tasks. If there is a nutritional team present in the facility, the treatment will be handled cooperatively by the team. In the home setting, the general practitioner or primary physician will usually play the coordinating role and a portion of the care can be delegated to home care (medical technical treatment team, dietician). Firms that specialize in home care may support the care.

 

Relevant information for the dietician:

• Diagnosis: underlying condition, any comorbid conditions
• Symptoms: anorexia, nausea, vomiting, diarrhea, other loss (e.g. through fistulae)
• Laboratory tests: electrolytes, bicarbonate, glucose levels, live enzymes such as bilirubin, AST, ALT, gamma GT, alkaline phosphatase, renal function, (urea, creatinine), vitamines (specifically vitamins B1, B12, A and D), trace elements (particularly iron)
• Medication: type + route of administration + any interactions with the nutritional therapy selected
• Other: height, (changes in) weight, fluid requirements

 

Aims of the diet:

• To optimize the nutritional status when not enough food can be taken in by mouth, partly depending on the underlying disease and treatment.

 

Characteristics of the diet:

• Energy: basal metabolism (Harris & Benedict) + extra allowances, evaluation of weight fluctuations and intake to customize the individual requirements
• High-protein: 1.2-1.5 g/kg actual body weight, depending on liver and kidney function
• Fluids: at least 1.5 L, not including fluid loss.

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• It is recommended to have supervision of parenteral nutrition in the home setting be handled by a specialized team. In the Netlerlands, there are two specialized teams: Voedingsteam Universitair Medisch Centrum Nijmegen (UMCN) and Voedingsteam Academisch Medisch Centrum in Amsterdam.
• The nutritional requirements depend on the underlying clinical picture and its associated treatment, rather than on the route of administration.

 

References:

Asseldonk G.A.E.G. van; J.J. van Duinen; M. Former-Boon; R. van Nuland Zakboek ziektegerelateerde ondervoeding bij volwassenen, Bohn, Stafleu van Loghum 2007 (isbn 9789031351305)

 

Barendregt K, Hogen E van de, Soeters PB. Depletie. In: Leeuwen PAM van. Klinische Voeding. Houten: Bohn Stafleu Van Loghum: 2000

 

Binsbergen JJ, Kalmijn S, Ocké MC. Voeding en chronic ziekten. Utrecht: Uitgeverij van Wees: 2001

 

ESPEN Guidelines on adult enteral nutrition. British Journal of Nutrition 2007: 98:253-9

 

ESPEN guideliness on adult parenteral nutrition. Clinical Nutrition 2009; 28:359-479

 

Leeuwen PAM van. Klinische Voeding. Houten: Bohn Stafleu Van Loghum: 2000

 

Artificial Nutrition was written by Cora Jonkers-Schuitema, dietician in the nutritional team at the Academisch Medisch Centrum (AMC), also writing on behalf of the NEtherland Society for Parenteral and Enteral Nutrition (NESPEN) and the Nederlands Voedingsteam Overleg (NVO).