Nutrition Support Methods and Risks

Surgical Enterostomies

Gastrostomy Procedure

For temporary access, a Foley catheter is placed through the abdominal wall into the stomach. The balloon at its end is inflated inside the stomach to secure the tube. Gastrostomy can be used for a long time, with less danger and inconvenience than nasogastric tubes. Complications arise when the tube is dislodged, skin erosion occurs, or there is leakage of gastric contents or formula, causing local infection or peritonitis.

Jejunostomy Procedure

Jejunostomy involves creating a jejunal loop brought to the abdominal wall and inserting a tube into the jejunum through the wall. Surgical jejunostomy also achieves the same reduction in aspiration risk as nasojejunal feeding and less frequently causes erosion and leakage than gastrostomies. The very fine size of needle catheter jejunostomies can pose challenges for continuous nutrient infusion.

Enteral Nutrition Complications

• Hyperosmolar syndrome (related to infusion rate)
• Bacterial contamination
• Trauma from tubes/insertion sites
• Necrosis of nasal septum and ala
• Esophageal ulcers
• Bronchitis
• Ostomy site infections
• Fluid and electrolyte imbalance
• Aspiration pneumonia

Parenteral Nutrition

If a patient cannot receive nutrients via the GI tract, nutrition support requires choosing between central or peripheral venous access. Factors influencing this decision include: the planned duration of total parenteral nutrition, the required nutrient density (which determines solution hyperosmolarity and feasibility of peripheral vs. central administration), the patient's fluid tolerance, and the condition of peripheral veins (peripheral access may be used if veins are good and nutrient requirements are not high).

Indications for Parenteral Nutrition

Nutrient Management via Intravenous Route for Patients with Partial or Total Digestive Tract Incompetence.

Specific Indications

• Severe sepsis
• Ileus / Obstruction / Intestinal Thrombosis
• Ulcerative Colitis / Crohn's Disease
• Severe Pancreatitis
• Hyperemesis Gravidarum

Parenteral Nutrition Complications

• Catheter-related:
  • Trauma: Pneumothorax, Hemothorax, Vessel perforation, Chylothorax, Nerve plexus injury
  • Infection: Catheter sepsis
• Solution-related:
  • Air embolism
  • Sepsis
  • Allergic reactions (especially to lipids)
  • Thrombophlebitis
• Metabolic:
  • Hyperglycemia
  • Fluid and electrolyte imbalances
  • Liver dysfunction
  • Fatty liver
  • Metabolic acidosis
  • Hyperosmolar coma

Enteral Nutrition in Sepsis

Severe sepsis develops in approximately 1% of hospitalized patients and may progress to septic shock and multiorgan failure. This leads to a mortality rate of 20-48%, depending on severity. We can define sepsis as the systemic response to infection. This systemic response has implications for metabolic and immune systems.

Role of the Bowel

The gastrointestinal tract's function is not only to absorb nutrients; it also plays a vital role in the immune system of both healthy and critically ill patients. Under certain conditions, stimulating the intestine attenuates the stress response, prevents atrophy, improves intestinal barrier function, and prevents atrophy of gut-associated lymphoid tissue (GALT).

The GALT system is the most important defense system of the mucosal surface, producing IgA via lymphocytes. It includes Peyer's patches, mesenteric lymph nodes, intraepithelial lymphocytes, and lamina propria.