Access Routes for Nutritional Therapy

Abstract

Enteral nutrition (EN) and total parenteral nutrition (TPN) may provide life-sustaining therapy for surgical patients. The duration of nutritional therapy (enteral or parenteral) implies distinct access routes. We review the main aspects related to access routes for nutrient delivery. The enteral route, whenever feasible, is preferred. For EN lasting less than 6 weeks, nasoenteric tubes are the route of choice. Conversely, enterostomy tubes should be used for longer-term enteral feeding and can be placed surgically or with fluoroscopic and endoscopic assistance. The first choice for patients who will not be submitted to laparotomy is percutaneous endoscopic gastrostomy. Postpyloric access, although not consensual, must be considered when there is a high risk of aspiration. For intravenous delivery of nutrients lasting less than 10 days, the peripheral route can be used. However, because of frequent infusion phlebitis, its role is still in discussion. Central venous catheters (CVCs) for TPN delivery may be (1) nonimplantable, percutaneous, nontunneled-used for a few days to 3 to 4 weeks; (2) partially implantable, percutaneous, tunneled-used for longer periods and permanent access; or (3) totally implantable subcutaneous ports-also used for long-term or permanent access. The subclavian vein is usually the insertion site of choice for central venous catheters. Implantable ports are associated with lower rates of septic complications than percutaneous CVCs. The catheter with the least number of necessary lumens should be applied. Central venous nutrient delivery can also be accomplished through peripherally inserted central catheters, which avoid insertion-related risks.

When do our patients need a pinch of salt

“…53 Studies done to evaluate incidence of thrombophlebitis after infusing high osmolar parenteral nutrition solutions (upto 1200 mosmol/L) into a peripheral vein for short durations (around 7 days) indicate no significant increase in thrombophlebitis when used for short duration. [54][55][56] Taking cue from these studies the authors conclude that in an emergency it would be safe to administer a 250 ml bolus of 3% saline solution, which has an osmolarity of 1026 mosm/kg (osmolarities comparable to those of solutions of sodium bicarbonate and 50% dextrose in water), via peripheral vein. It would be reasonable to insert a central venous catheter if a more hypertonic saline is required or if the solution is required for a prolonged period of time.…”

Enteral feeding via jejunostomy as a cause of intestinal perforation and necrosis

“…It is performed when EF is expected to last for long periods of time (1)(2)(3)(4)(5). The introduction technique could be surgical, endoscopically guided, o radiologically guided (2,3).…”

Modificação de dispositivo para gastrostomia endoscópica percutânea pela técnica de punção: utilização em pacientes com neoplasia maligna de cabeça e pescoço

“…As sondas nasogátricas ou nasoenterais podem ser colocadas manualmente e, quando necessário, sob controle endoscópico ou radiológico 30,31 . Embora sejam de calibre reduzido e produzida com material flexível, não deixam de ser incômodas e ocasionar aspecto externo pouco desejável 27 .…”

“…Embora sejam de calibre reduzido e produzida com material flexível, não deixam de ser incômodas e ocasionar aspecto externo pouco desejável 27 . Estes dispositivos ainda são responsáveis por complicações, tais como: ulcerações laríngeas, esofagite por refluxo, aspiração respiratória e pneumonia de repetição 27,31 . Seu uso prolongado pode provocar sinusite e erosões na narina.…”

“…As sondas de gastrostromia e jejunostomia podem ser instaladas sob controle endoscópico ou radiológico, por meio de laparoscopia ou por via cirúrgica aberta 26,30,31,32 .…”