Enteral (NG/PEG) Nutrition
In recent years, research has increased on the use of iso-osmolar
tube feedings by either a small-bore nasogastric (NG) feeding
tube, or a percutaneous endoscopic gastrostomy (PEG) tube
as an alternative to parenteral (intravenous) nutrition.
Sometimes, the tube will be advanced into the jejunum instead
for added safety and tolerance.
One should not assume
that the metabolic complications of parenteral nutrition
will avoided by use of enteral nutrition, nor is it without
risk. The most common risks include tube displacement,
pulmonary aspiration and poor patient tolerance. Many women
with HG
have delayed gastric emptying, extremely sensitive gag
reflexes, and frequent vomiting which make this therapy intolerable
and somewhat risky. Some of these women report repeated
dislodgements
due to vomiting.
The benefits of avoiding gut atrophy and
improved nutrient metabolism, may not outweigh the risks
in this patient population, especially during the acute
phase of illness. Further, many women benefit greatly from
a period
of gut rest, yet require nutritional support after
weeks of vomiting and limited intake. Intravenous
nutrition is
preferred initially in these women.
Research & Risks
A few studies have demonstrated that enteral nutrition may
be a safe and effective alternative to TPN in selected pregnant
women with hyperemesis gravidarum (HG) who have failed conventional
treatment. However, these studies have only a few patients
of varying
severity,
and thus should be interpreted cautiously. It is not yet
clear as to which women with HG are the best candidates.
It should be noted that women with HG have several risk factors
for aspiration, as well as Refeeding Syndrome, both potential
complications of enteral nutrition. (See lists below.)
Careful
monitoring is important when initiating this therapy. The
best advice when initiating nutritional support
is to "start low and go slow". In women who continue
to vomit, more aggressive antiemetic therapy should be considered,
and/or an alternative mode of nutritional support.
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Risk Factors for Aspiration
- Decreased level
of consciousness (sedative medication)
- Diminished
gag reflex
- Incompetent low esoph. sphincter
- GI reflux
- Supine position
- Use of large-bore feeding
tubes
- Large gastric residuals
- Delayed gastric emptying
- Vomiting or retching
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Patient's at Risk for Refeeding Syndrome
- Chronic malnutrition
- Prolonged fasting
- Prolonged IV hydration
- Significant stress and nutrient depletion
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| Potential
Complications of Enteral Nutrition |
| Metabolic
Complications |
| Electrolyte imbalances (K+,
Na+) |
Due to fluid imbalance, renal
impairment, diarrhea, Refeeding syndrome. |
| Hyperglycemia |
Too many calories or lack of
adequate insulin. |
Dehydration
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Tube clogging
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Tube malposition
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Aspiration
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Nausea and vomiting
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Diarrhea
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Constipation
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| Malabsorption/maldigestion |
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| Refeeding syndrome |
The metabolic cascade of events
that takes place when a malnourished patient is
refed. Hypophosphatemia, hypokalemia, hypomagnesemia,
body-fluid disturbances, vitamin deficiencies such
as thiamine, cardiac arrhythmias, and congestive
heart failure may result. |
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| Adapted from www.rxkinetics.com, www.medscape.com, and other sources. |
| Offsite
Research:
Enteral nutrition by nasojejunal tube in hyperemesis gravidarum.
Pearce CB, Collett J, Goggin PM, Duncan HD.
Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK.
Clinical Nutrition 2001 Oct;20(5):461-4.
We describe two cases in which self-propelling, blind placed nasojejunal tubes were placed in severe hyperemesis gravidarum. This method provides an alternative to parenteral nutrition and to percutaneous endoscopic tubes, is well tolerated, cost effective and with a low rate of complication. Both mothers were given nutritional support at home, had normal subsequent pregnancies and normal babies.
Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases.
Serrano P, Velloso A, Garcia-Luna PP, Pereira JL, Fernadez Z, Ductor MJ, Castro D, Tejero J, Fraile J, Romero H.
Department of Clinical Nutrition, Hospital Universitario Virgen del Rocio, Sevilla, Spain.
Clinical Nutrition 1998 Jun;17(3):135-9.
We describe the first two cases in which percutaneous endoscopic gastrojejunostomy was used as a means to provide enteral nutrition in severe hypermesis gravidarum. The use of this method of enteral access provided an alternative to parenteral nutrition, was well tolerated, cost-effective and had no major complications. In both cases the nutritional goal for mothers as well as appropriate fetal growth and development were achieved.
Refeeding syndrome induced by cautious enteral alimentation of a moderately malnourished patient.
Vaszar LT, Culpepper-Morgan JA, Winter SM.
Section of Pulmonary and Critical Care Medicine, Norwalk Hospital/Yale University School of Medicine, CT 06856, USA.
Gastroenterologist 1998 Mar;6(1):79-81.
More
PubMed Research on Hyperemesis and Enteral Nutrition »
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Updated on:
Aug. 09, 2006 |
