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...
Nội dung trích xuất từ tài liệu:
Chapter 073. Enteral and Parenteral Nutrition (Part 4) Chapter 073. Enteral and Parenteral Nutrition (Part 4) Although PN was initially relatively expensive, its components are oftenless expensive than specialty enteral formulas. Percutaneous placement of acentral venous catheter into the subclavian or internal jugular vein withadvancement into the superior vena cava can be accomplished at the bedside bytrained personnel using sterile techniques. Peripherally inserted central catheterscan also be placed within the lumen in the central vein, but this technique isusually more appropriate for non-ICU patients. The subclavian or internal jugularlines can be changed over a wire, but this carries a greater risk of pneumothorax orserious vascular damage. The peripherally inserted catheters are subject toposition-related flow, and the catheter cannot be changed over a wire. Inserting anasogastric tube is a bedside procedure, but many critically ill patients haveimpaired gastric emptying that increases the risk of aspiration pneumonia. Thisrisk can be reduced by feeding directly into the jejunum beyond the ligament ofTreitz. This usually requires fluoroscopic guidance or endoscopic placement. Inpatients who have planned laparotomies or other conditions likely to require aprolonged need for SNS, it is advantageous to place a jejunal feeding tube at thetime of surgery. Although most SNS is delivered in hospitals, some patients require it on along-term basis. If they have a safe environment and a willingness to learn theself-care techniques, SNS can be administered at home. The clinical outcomes ofpatients with severe intestinal disorders treated with home PN or EN aresummarized in Table 73-2. PN infused at home is usually cycled overnight to givegreater daytime freedom. Other important considerations in determining theappropriateness of home PN or EN are that the patients prognosis is longer thanseveral months and that the therapy benefits quality of life. Table 73-2 Summary of Outcomes for Patients on Home Parenteraland Enteral Nutrition (HPEN) Therapy Rehabi Complic Status, % at 1 litationc ationsd per yearb Status, % in Patient-Year 1st year Di N C H Nagnosis 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.ohns 62 6 6 0 5 0 8 .9 1disease Isc 3 4 1 1.hemic 31 9 7 7 8 9 3 1 .4 1boweldisease M 2 4 1 1.otility 99 5 7 1 4 1 9 9 2 .3 1disorder Co 1 4 2 1.ngenital 72 4 2 7 3 7 1 .1 0boweldefect Hy 1 0 1 3.peremesis 12 8 00 00 3 6 .5 5gravidarum Ch 1 1 1 2.ronic 56 2 0 2 0 0 8 .2 5pancreatitis Ra 1 4 0 1.diation 45 8 7 8 9 2 2 9 .8 1enteritis Ch 1 3 1 1.ronic 20 3 3 7 4 3 3 8 0 .7 4adhesiveobstructions Cy 5 1 0 3.stic 1 7 0 8 3 6 4 6 6 .8 7fibrosis 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 9disordersofswallowing Ca ...