E63.9
Establish a multidisciplinary nutrition support team to assess and address the nutritional requirements of patients. This team should include a dietician.
Nutrition support should be considered in patients at risk, defined as those who have a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism.
Oral feeding, if feasible, is preferred.
Enteral tube feeding is the next best option.
Total parenteral nutrition (TPN) is indicated in exceptional circumstances.
For short-term care (≤ two weeks), the current standard formulas in multi-chamber bags that have a long shelf-life are considered to provide adequate nutritional support. Clinicians should be aware of the possibility of clinically important hypovitaminosis in individual patients, and replace selected vitamins where appropriate.
Refer to the most current version of the National Department of Health Parenteral Nutrition Practice Guidelines for Adults, available at: www.health.gov.za
In selecting the treatment modality, the team should consider:
- The likely duration of nutrition support.
- Patient activity levels and the underlying clinical condition, e.g. catabolism.
- Gastrointestinal tolerance, potential metabolic instability and risks of re-feeding.
Potential complications harms of nutritional support include:
- Re-feeding syndrome: Hypophosphataemia occurs when patients are re-fed too quickly with high carbohydrate feeds. The syndrome usually begins within 4 days of re-feeding. A multitude of life-threatening complications involving multiple organs may occur, causing: respiratory failure, cardiac failure, cardiac dyshythmias, rhabdomyolysis, seizures, coma, red cell and leukocyte dysfunction. The most effective way to prevent re-feeding syndrome is that feeds should be started slowly with aggressive supplementation of magnesium, phosphate and potassium.
- Diarrhoea.
- Lactose intolerance.
Regularly review the need for ongoing therapeutic nutritional support.
Vitamin and mineral supplementation should be considered on a case-by-case basis.
Enteral tube feeding
Enteral tube feeding should be used in patients who cannot swallow or who are at risk of aspiration.
Patients should be fed via a nasogastric tube unless this is contra-indicated.
Patients with upper gastro-intestinal dysfunction (or an inaccessible upper gastro-intestinal tract) should receive post-pyloric (duodenal or jejunal) feeding.
Percutaneous endoscopic gastrostomy feeding should be used in patients likely to need long-term (≥4 weeks) enteral tube feeding.
Parenteral feeding
The team should consider parenteral nutrition in patients who are malnourished or at risk of malnutrition and fit the following criteria:
- inadequate or unsafe oral and enteral tube nutritional intake, or
- a non-functional, inaccessible or perforated (leaking) gastrointestinal tract.
Note: For short-term care, the current standard formulas in multi-chamber bags that have a long shelf-life are considered to provide adequate nutritional support.
The addition of glutamine does not confer any clear clinical benefits and is thus not recommended.
Parenteral nutrition can be withdrawn once adequate oral or enteral nutrition is tolerated and nutritional status is stable. Withdrawal should be planned and done in a stepwise way with a daily review of the patient’s progress.