Enteral (NG/PEG) Nutrition
In recent years, research
has increased on the use of feedings by either a nasogastric (NG), or a percutaneous
endoscopic gastrostomy (PEG) tube as
an alternative to parenteral (intravenous) nutrition. This
is mostly attributed to decreasing the cost of medical care,
and increasing safety. A NG tube is passed through the nose
to the stomach or jejunum, and the PEG requires a surgical
procedure to implant it through the abdomen into the stomach.
Sometimes, the tube will be advanced into the jejunum for added
safety and tolerance.
However, it should not be assumed that
the metabolic complications of parenteral nutrition will
be 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 slow emptying of their stomachs,
extremely sensitive gag reflexes, and frequent vomiting which
make NG
feedings intolerable and somewhat risky. Some of these women
report repeated tube dislodgements due to vomiting. Further,
many women benefit greatly from a period of gut rest, yet
require nutritional support due to 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 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 below for more info). Careful
monitoring is important when initiating this therapy. In
women who continue to vomit, more aggressive antiemetics
should be
considered, and/or an alternative mode of nutritional support.
|
Risk Factors for Aspiration:
- Decreased level
of consciousness (sedative medication)
- Diminished
gag reflex
- Acid reflux
- Supine position (laying down)
- Use of large diameter
tubes
- Large gastric residuals
- Delayed gastric emptying
- Vomiting or retching
|
|
Patient's at Risk for Refeeding Syndrome:
- Chronic malnutrition
- Prolonged fasting
- Prolonged IV hydration
- Significant stress and nutrient depletion
|
| Electrolyte imbalances (K+,
Na+) |
Due to fluid imbalance, renal
impairment, diarrhea, Refeeding syndrome. |
| Hyperglycemia |
Too many calories or lack of
adequate insulin. |
Dehydration
|
|
Tube clogging
|
|
Tube malposition
|
|
Aspiration
|
|
Nausea and vomiting
|
|
Diarrhea
|
|
Constipation
|
|
| Malabsorption/maldigestion |
|
| 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. |
|
| |
| Adapted from http://www.rxkinetics.com/tpntutorial/2_3.html,
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.
More PubMed Research on Enteral Nutrition and Hyperemesis »
|
|
Updated on:
Aug. 09, 2006 |
