Page 30 - 58peadiatric-surgery-speciality1-7_opt

32 Nutritional Support
Parenteral feeding fevers or is clinically deteriorating, the parenteral catheter will need to
Parenteral feeding can be given as an adjunct to other nutrition or as be removed and the sepsis controlled before consideration is given to
total parenteral nutrition if the period of starvation is prolonged or if placing a new catheter, depending on the condition of the patient.
enteral feeding is going to be impossible. Administration can be by a Poor nutrition in the surgical patient affects the clinical course of the
peripheral line for those requiring immediate support but whose con- disease and the clinical outcome of the patient.
11
ditions are expected to improve within 1–2 weeks. Lower dextrose Prevention of Poor Nutrition
concentrations of no more than 12.5% dextrose should be given through
a peripheral vein. A peripheral vein can be used only for short-term Nutrition starts in utero. Attention must be given to appropriate educa-
infusion and must be checked on a frequent basis and discontinued tional programmes to ensure that pregnant women are well nourished
immediately if there are any signs of thrombophlebitis. A catheter can and eating suitably balanced diets. This can involve addressing nutri-
also be placed through a peripheral vein and then advanced until it is tional taboos, such as the belief that if the mother eats eggs in preg-
in a central position. The pressure from these catheters correlates well nancy, the delivery will be difficult.
with centrally inserted catheters. 12 Nutrition for children younger than five years of age must ensure
Administration can also be through a centrally placed venous line. adequate intake of calories, minerals, and vitamins that will maximise
It is important to ensure that the tip of the central catheter is adequately their growth. Specific known dietary deficiencies peculiar to some
placed before the solutions are infused. With centrally placed catheters, areas (e.g., iodine deficiency, which causes specific surgical problems)
it is possible to give higher concentrations of dextrose and thus deliver need to be addressed.
more calories. Preoperative assessment of surgical patients must include their
In all cases, nutritional support must include lipid, an energy source nutritional status, and any deficiencies identified must be corrected
(usually dextrose), and amino acids. In environments where not all wherever possible before surgical intervention is undertaken. Where
of these preparations are available, anecdotal experiences suggest this is not possible, postoperative management must include special
some benefit in the use of alternative sources, including aliquots of attention to nutritional correction.
fresh frozen plasma in the short term for small babies or intravenous Ethical Issues
preparations of amino acids, which can be administered with dextrose Traditionally and culturally, food and water are considered basic to the
preparations in the short term. needs of each individual person. The modern practice of delivering
Parameters for Monitoring Nutritional Outcomes nutrition and fluids via enteral and parenteral routes now challenges
Nutritional outcomes are monitored, including a daily assessment of the these values, adding on religious and moral dimensions as well as
overall clinical status of the patient, the state of hydration, and weight playing out issues of human rights. This is particularly the case when
change. Ideally, it is also necessary on a daily basis to estimate electro- children have complex congenital abnormalities with poor prognosis.
lyte, creatinine, and urea levels; serum glucose levels; and magnesium, Decisions on starting or stopping feeding by oral, enteral, or parenteral
phosphorus, and calcium. Once the patient has stabilised, these param- means in most countries in Africa requires physicians to adhere to
eters can be assessed much less frequently. strict institutional policies, which should be developed for this purpose,
as the increasing possibility of legal challenges cannot be ruled out.
13
Postoperative Complications More complex discussions of specific issues is beyond the scope of this
Complications of Enteral Feeding book. Additionally, resource constraints in the region would affect the
Complications with enteral feeding are less common than with parenteral range of options available to the surgeon and the available modes of
nutrition. Such complications are summarised here. If the feeding con- administration in terms of equipment availability.
tains an excess of electrolytes, these can be absorbed into the circulation, Evidence-Based Research
resulting in electrolyte imbalance. The concentration of the feeding or Tables 6.5 and 6.6 present, respectively, a guideline for nasojejunal tube
the rate of feeding may not be tolerated, with resultant nausea, abdomi- placement and a review of various feeding issues in preterm babies.
nal cramps, vomiting, diarrhoea, or—less often—constipation. These
are usually managed symptomatically, and often just a dilution of the Table 6.5: Evidence-based research.
solution given by introducing water into the mixture or slowing the rate Title Naso-jejunal tube placement in paediatric intensive care
of delivery will resolve the problem over a period of time. Rarely will Authors McDermott A, Tomkins N, Lazonby G
the feeding have to be discontinued. Pulmonary aspiration may occur if
9
amounts fed are not controlled. This is particularly true if the patient has Institution The General Infirmary at Leeds, UK
swallowing problems and therefore cannot protect the airway. Reference Paediatr Nurs 2007; 19(2):26–28
If there is any question about satisfactory placement of the tip of the Problem In critically ill children, intragastric feeding is often poorly
enteral tube, a simple plain radiograph of the abdomen will be able to tolerated.
confirm the placement of the catheter if it is radio-opaque. If the tube Intervention A guideline for bedside nasojejunal tube (NJT) placement
is not radio-opaque, a small amount (5 ml) of contrast can be placed in has been developed by a multidisciplinary group.
the catheter prior to the x-ray. Comparison/ Audit of the practice was carried out after the
control implementation of the guidelines. Fifty-eight percent of
Complications of Parenteral Feeding (quality of the children would have definitely or probably started on
Complications of parenteral feeding are numerous and include bacter- evidence) parenteral nutrition.
aemia and septicaemia, air embolus, pneumothorax, hypo- or hypergly-
caemia, thrombosis, hyperosmolality, metabolic acidosis, and hyperam- Outcome/ Reduction in requests for NJT placement under x-ray
monaemia. Other complications include cholestasis, migration of the effect screening and reduction in the use of medication for the
placement.
catheter, and catheter blockage. Each complication has to be managed
on its own merits. The metabolic complications, such as hypo- or Historical Improved tolerance of enteral feeding for better nutritional
hyperglycaemia and metabolic acidosis, can be managed by adjusting significance/ outcomes in intensive care units.
the parenteral nutrition solution. The most serious complication is sep- comments
sis, for which antibiotics are given first and then adjusted based on the
organisms identified by blood culture. If the patient continues to have