Chapter 073. Enteral and Parenteral Nutrition (Part 4)

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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...

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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 Rehabi Complic Status, % at 1 litationc ationsd per yearb Status, % in Patient-Year
1st year Di N C H N agnosis umber ge in ull ontinue ied PEN onHPE in Year Surv Oral d on N Group s ivala Nutr HPEN on ition Rx Ther apy Home Parenteral Nutrition Cr 5 2 0 1. ohn's 62 6 6 0 5 0 8 .9 1 disease Isc 3 4 1 1. hemic 31 9 7 7 8 9 3 1 .4 1
bowel disease M 2 4 1 1. otility 99 5 7 1 4 1 9 9 2 .3 1 disorder Co 1 4 2 1. ngenital 72 4 2 7 3 7 1 .1 0 bowel defect Hy 1 0 1 3. peremesis 12 8 00 00 3 6 .5 5 gravidaru m Ch 1 1 1 2. ronic 56 2 0 2 0 0 8 .2 5 pancreatit is
Ra 1 4 0 1. diation 45 8 7 8 9 2 2 9 .8 1 enteritis Ch 1 3 1 1. ronic 20 3 3 7 4 3 3 8 0 .7 4 adhesive obstructio ns Cy 5 1 0 3. stic 1 7 0 8 3 6 4 6 6 .8 7 fibrosis Ca 2 8 1 3. ncer 122 4 0 6 3 9 7 4 .1 3 AI 2 6 1 3. DS 80 3 0 3 3 3 9 .6 3
Home Enteral Nutrition Ne 1 2 0 0. urologic 134 5 5 9 5 8 4 1 .3 9 disorders of swallowi ng Ca 1 6 0 2. ncer 644 1 0 0 9 1 9 1 .4 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.