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Clinical Case StudyBackgroundPercutaneous endoscopic gastrostomyPercutaneous endoscopic gastrostomy (PEG) is an endoscopic operation in which a feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids, and medications to be administered directly into the stomach through the tube. It is a type of enteral nutrition for patients with functional gastrointestinal tract who are unable to meet their nutritional needs orally. Tube feedings can be administered continuously using a pump or via bolus feedings using a syringe or under gravity. Continuous tube feeding has a low infusion rate which is ideal for inpatient, bedbound, high aspiration risk, acutely ill patients. Bolus feeding is ideal for people who live at home because it allows freedom of movement for the patients. However, the infusion rate (240-480ml in 5-20mins) is higher which may cause GI intolerance compared to continuous feeding CITATION Los05 \l 1033 (Lo¨ser, et al., 2005). EN IndicationEnteral nutrition is indicated in patients who have a functional GI tract but their oral intake may not be possible, adequate, or safe. It is also indicated for people who are malnourished or at risk of malnutrition, have prolonged poor appetite, have impaired swallowing function. Conditions include anorexia, dysphagia, esophageal obstruction, esophageal dysmotility, and reduced level of consciousness. EN can also be provided in patients with short bowel syndrome if there is more than about 100 cm of jejunum CITATION Llo04 \l 1033 (Lloyd & Powell-Tuck, 2004) CITATION Kir95 \l 1033 (Kirby & Delegge, 1995). ComplicationsMajor complications associated with PEG tubes include necrotizing fasciitis, intraperitoneal bleeding, bowel perforation, septicemia, buried bumper syndrome, and aspiration pneumonia. Minor complications include skin abscess, cellulitis, tube blockages, the tube falling out, site infections, and leakage of gastric contents. The most common complications related to PEG tubes are local infection, skin excoriation and blockages. Preventative strategies include ensuring the tube is properly secure, use of topical antibiotics, frequent cleaning and dressing changes, and cleansing the site with warm water and soap twice daily CITATION Lyn04 \l 1033 (Lynch & Fang, 2004) CITATION Bot98 \l 1033 (Botterill, Miller, Dexter, & Martin, 1998).Dysphagia and AspirationDysphagia is defined as swallowing difficulty. People with dysphagia may experience pain while swallowing, they may be unable to swallow, or may have trouble swallowing liquids and foods safely. Aspiration is a condition when foods or fluids go into the lungs instead of the stomach. When people aspirate they will cough in order to clear the food or fluid out of their lungs. Eating becomes a big challenge for people with dysphagia and people who are at risk for aspiration. They are also at risk for malnutrition due to inadequate oral intake CITATION NID10 \l 1033 (Clearinghouse, 2010). FormularyJevity 1.2 high-protein, fiber-fortified formula that provides complete, balanced nutrition for long- or short-term tube feedingOsmolality, mOsm/kg H2O:?45018 g fiber in 1000mLOsmolite 1.2a source of complete, balanced nutrition and a high-protein, low-residue formula for tube-fed patients who may benefit from increased protein and caloriesOsmolality, mOsm/kg H2O:?360No fiberCase StudyJB is a 92 year old male admitted with inability to take adequate oral nutrition, aspiration pneumonia, and features of hypovolemia. He coughed when he ate for the past six months and avoided the dining room. During this hospital stay, he underwent percutaneous endoscopic gastrostomy (PEG) tube placement and started tube feeding. The speech-language pathologist’s evaluation allowed for small sips of water and possibly pureed diet for pleasure feeds post PEG placement. JB was seen before the procedure and an initial nutrition assessment was conducted. JB and his daughter-in-law expressed concerns over the procedure, types of tube feeding formula, and new lifestyle adaptations. All nutrition related questions from them were clarified. Nutrition follow-ups were also conducted over the course of his hospital stay.Diagnosis: dysphagia, aspiration pneumonia, hypokalemia, mild anemia, pleural effusionPast medical history: venous insufficiency, peripheral neuropathy, osteoarthritis, GERD, hyperlipidemia, atrial fibrillation, coronary artery disease, diabetes mellitus, osteoporosis, hypertension, benign prostatic hypertrophySocial History: JB is a pharmacist, married, never smokes, and rarely drinks alcohol. He is full resuscitation until conditions of his advanced directives apply. His daughter-in law is an ophthalmologist and his son is a rheumatologist. Anthropometric measurements: Height: 175cm/ 68.9 inches, Weight: 85.7kg / 188.5lbs, BMI: 28, IBW: 78.2kg / 172lbs, UBW: unable to obtainNutrient needs: Estimated energy needs 1714 – 2100kcal (20-25kcal/kg); Estimated protein needs 85-100g protein (1-1.2 g/kg)Biochemical data: Reference range2/12/22/32/42/52/62/7Reason for AbnormalitySodium (mMol/L)135-145136138138139139141140Potassium (mMol/L)3.8 - 54.43.73.73.43.83.23.3Decreased w/ diarrhea, K depleting diureticsGlucose (mg/dL)70-90121126135114133113113DMBUN (mg/dL)8-2229231715191920Renal insufficiency, dehydrationCreatinine (mg/dL)0.4-1.21.31.111.11.21.11Renal insufficiency, dehydrationPhosphorous (mg/dL)2.4-4.32.32.12Catabolic state anabolic stateMagnesium (mg/dL)1.3-2.11.81.71.6Glucose POCT93-189 mg/dLDMB type natriuretic peptide(pg/mL)<10015351474Increased in CHF2/72/62/52/42/32/22/1Nutrition Implication / side effectAmlodipine××××××Decrease Na may be recommendedMetoprolol×××××Dry mouth, diarrhea, N/VAzithromycin×××××DiarrheaPPI×××××May decrease absorption of Fe, vit B12SSI×××DM, HypoglycemiaZosyn×××××diarrheaKCl×××××GI irritation, N/V, diarrheaLasix×××××Decrease K level in bloodProbiotic1 pkt1pktHelp restore gut microbiomeInitial Nutrition AssessmentDuring the initial nutrition assessment, JB was NPO except for sips of water and medications while he waited for a PEG placement. He reported he had poor PO intake prior to admission, however, he was not able to give a timeline for this poor intake. Patient seemed anxious about starting the tube feed and was concerned about the volume per feed and calories he needed per day. Questions about choices of formula, nutrient needs, and continuous vs bolus feeds were answered. Patient preferred to start on bolus feeds over continuous feeds because bolus feeding allows him to have freedom of movement. A discussion with the attending physician was conducted. The physician agreed with starting with bolus feeds to assess tolerance since he expected JB to be discharged soon and would be discharged with bolus feeds. Basic metabolic panel, magnesium, and phosphorus were ordered due to patient was at risk of refeeding syndrome.PES: Inadequate oral intake related to swallowing dysfunction as evidenced by poor PO intake PTA and patient NPO.Intervention: Jevity 1.2 bolus feed via PEG: 2 cans at breakfast, 2 cans at lunch, 2 cans a dinner, 1 can 2-3 hours after dinner feed (total 7 cans daily); 100mL free water flush before and after each feed (200mL per meal, total 800mL free water flushes)Goal: patient to meet nutritional needs via total enteral nutrition with toleranceNutrition prescription: Bolus Jevity 1.2, 7 cans/day (total nutrition provided: 1995kcal, 93g protein, 1337 cc free water and 800 free water flush = 2137 cc fluid)Monitoring and Evaluation: Indicator: enteral nutrition; Criteria: tolerate bolus feed at goal; indicator: electrolytes and renal profile; criteria: within normal limitNutrition Follow-up 1During the first follow-up, JB was seen to assess his tolerance of the tube feeding. He reported having diarrhea after each feed. His nurse reported that JB had refused his feeding that morning due to the diarrhea. Due to diarrhea, his formula was changed to Osmolite 1.2, a formula with low residual, no fiber, and lower osmolality. The free water flush was decreased out of concern for high fluid volumes due to diarrhea and pleural effusion. Nutrition dx: 1) Altered GI function related to new PEG as evidenced by diarrhea after each feed. 2) Inadequate oral intake --- regressingNutrition prescription: Osmolite 1.2 bolus feed via PEG: 2 cans at breakfast, 2 cans at lunch, 2 cans a dinner, 1 can 3 hours after dinner feed (total 7 cans daily); 50mL free water flush before and after each feed (100mL per meal, total 400mL free water flushes) --- to provide 1995 kcal, 92g protein, 1765 mL free water Nutrition Follow-up 2Thoracentesis was done and 1200cc of fluid was removed. During the follow-up visit, JB stated that he felt better. However, patient still had diarrhea after each feed. With the guidance of a dietitian, recommendations were made to space out the tube feed to improve tolerance and to administer a probiotic to balance the antibiotics currently prescribed. The volume of the tube feed was also reduced to 6 cans per day instead of 7. This plan was discussed with the physician and JB. The new tube feed schedule was updated with the nurse. Nutrition dx: 1) Altered GI function --- continues 2) Inadequate oral intake --- continuesNutrition prescription: Osmolite 1.2 bolus feed via PEG: 1 can each on following schedule: 8am, 9am, 12pm, 1pm, 5pm, 6pm (total 6 cans/day); 75mL free water flush after each feed (75 mL per feed, total 450 mL Free water flush) --- to provide 1710 kcal, 80g protein, 1620 mL free water Nutrition Follow-up 3Pt still had diarrhea but it had improved, which the nurse confirmed. The physician ordered a test to rule out C. difficile infection. Nutrition dx: 1) Altered GI function --- progressing 2) Inadequate oral intake --- progressingNutrition prescription: Osmolite 1.2 bolus feed via PEG: 1 can each on following schedule: 8am, 9am, 12pm, 1pm, 5pm, 6pm (total 6 cans/day); 75mL free water flush after each feed (75 mL per feed, total 450 mL Free water flush) --- to provide 1710 kcal, 80g protein, 1620 mL free water Nutrition Follow-up 4Patient’s tube feeding order was canceled accidentally; therefore, Jevity 1.2 was sent and administered to patient. Patient reported that he had diarrhea again after the tube feed. The correct tube feed order (Osmolite 1.2) was then reinitiated. Outcomes and LessonsA PEG placement was done and patient was started on tube feeding. Patient was discharged to senior living facility. Patient still had diarrhea at discharge but it had improved. He tolerated Osmolite 1.2 bolus feed, 6 cans per day with 75mL free water flush after each feed.During this assessment, I have learned that a patient with diabetes may not need a diabetes-specific enteral formula because the routine use of specialized formulas for patients with diabetes is controversial. According to American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), a recommendation of using specialized formulas for hospitalized patients with hyperglycemia cannot be made at this time. The impact of using these formulas on glycemic and lipid control was inconclusive. More research is needed on the use and efficacy of diabetic formulas. CITATION McM12 \l 1033 (McMahon, Nystrom, Braunschweig, Miles, & Compher, 2012). I also learned that diarrhea is a common complaint for tube feeding patients. Causes of diarrhea may include GI infection such as Clostridium difficile, motility disorders, some medications such as potassium and magnesium replacements, and antibiotics CITATION Ban09 \l 1033 (Bankhead, et al., 2009). One thing that I could have done differently was to start with a continuous tube feed and then transitioned to bolus because the infusion rate is much lower in continuous tube feedings. The patient might have better tolerated the formula if continuous infusion was initiated first when he was in the hospital. CITATION Str03 \l 1033 (Stroud, Duncan, & Nightingale, 2003). Works Cited BIBLIOGRAPHY Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., et al. (2009). Enteral Nutrition Practice Recommendations. Journal of Parenteral and Enteral Nutrition.Botterill, I., Miller, G., Dexter, S., & Martin, I. (1998). Deaths after delayed recognition of percutaneous endoscopic gastrostomy tube migration. British Medical Journal.Clearinghouse, N. I. (2010, October). Dysphagia. Retrieved from NIDCD: , D. F., & Delegge, M. H. (1995). American Gastroenterological Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition. American Gastroenterological Association.Lloyd, D., & Powell-Tuck, J. (2004). Artificial Nutrition: Principles and Practice of Enteral Feeding. Clin Colon Rectal Surg.Lo¨ser, C., Aschl, G., Hebuterne, X., Mathus-Vliegen, E., Muscaritoli, M., Niv, Y., et al. (2005). ESPEN guidelines on artificial enteral nutrition - Percutaneous endoscopic gastrostomy (PEG). Clinical Nutrition.Lynch, C., & Fang, J. (2004). Prevention and Management of Complications of percutaneous Endoscopic Gastrostomy (PEG) Tubes. NUTRITION ISSUES IN GASTROENTEROLOGY.McMahon, M., Nystrom, E., Braunschweig, C., Miles, J., & Compher, C. (2012). A.S.P.E.N. Clinical Guidelines: Nutrition Support of Adult Patients With Hyperglycemia. Journal of Parenteral and Enteral Nutrition.Stroud, M., Duncan, H., & Nightingale, J. (2003). Guidelines for enteral feeding in adult hospital patients. Gut. ................
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