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Enteral nutrition: complications can be avoided with the use of protocols and quality indicators

Maintaining or recovering nutritional status is essential if the individual is to react adequately to the aggressions of illness, trauma and treatment. Enteral Nutritional Therapy (ENT) is an efficient and safe strategy in this process, especially when there is the involvement and commitment of the patient themselves and their family and caregivers.

We've covered in our blog the main complications that can occur during ENT. On this occasion, we interviewed nutritionist Michelle Barone, from Ganep Nutrição Humana, an institution specializing in medical-nutritional therapy in Brazil.

According to the professional, most complications can be avoided by establishing protocols and quality indicators related to enteral nutrition, in other words: the cause of many complications is not just the enteral diet itself, but also factors related to the patient's situation. Complications are divided into a number of categories, including metabolic, gastrointestinal, mechanical, infectious and operational.

The most common metabolic complications are related to dehydration and hyperhydration, when there is an inadequate supply of water, which plays a dual role in Enteral Nutrition Therapy. In addition to hydration, water is important to prevent tube obstructions and should be administered after the infusion of the diet or medication. Other metabolic complications are hyper- and hypoglycemia, associated with: inadequate calorie supply, unplanned interruptions to ENT and the patient's own clinical condition.

One important change is Refeeding Syndrome. This occurs when malnourished patients or those undergoing prolonged fasting are fed again quickly and in large volumes. When this happens, the micronutrients that were deficient in the body are diverted, causing a rapid and significant drop in their plasma concentrations. This detour causes changes in the cardiovascular, hepatic, gastrointestinal, pulmonary, renal and hematological systems. In such cases, a gradual increase in the volume of the diet and the speed of infusion, as well as an adequate water supply, are the preventive measures.

Among the most frequent gastrointestinal complications when using enteral nutrition are diarrhea, vomiting, nausea and constipation. Gastroparesis can also occur, a difficulty in gastric emptying, making it slower. All of these complications are most commonly related to the use of certain medications, hydroelectrolytic disorders, rapid infusion of the formula, the temperature of the diet or even the patient's clinical situation. In more specific cases, these complications may be associated with the patient's intolerance to some component of the formula. In these cases, the following precautions are recommended:

- Gradual increase in diet volume and infusion rate;
Adequate water supply;
- Evaluation of the composition of enteral diets;
- Discuss the need for specific formulas when alterations are present;
- Opt for isotonic and fiber-free diets in case of gastroparesis;
- Avoid infusion of very cold diets.

Other important precautions

The right enteral diet involves care beyond the characteristics of the formula or its ingredients. Care such as the conservation and hygiene of the administration equipment is essential. Microbial contamination during the preparation of the enteral diet can lead to food poisoning, which is considered an infectious complication. Attention must also be paid to maintaining the tube in order to avoid interrupting treatment, suffering and impairing the patient's recovery.

A very important point is to make sure that the tube is changed frequently, keeping it clean and secure. This reduces the risk of the tube becoming dislodged, which would contribute to the infusion of the diet into the patient's trachea and lungs, potentially causing pneumonia and death. It is also recommended that the patient receives their diet in a sitting position or with the head of the bed raised between 45 and 90º, in order to avoid reflux and aspiration of the food. To avoid these complications, the following precautions are recommended:

- Check the positioning of the tube before starting the enteral infusion;
- Proper positioning: seated or with the head of the bed raised between 45 and 90°, before and after administering the diet;
- Avoid using very large probes;
- Ensure adequate fixation of the tube;
- Avoid using a nasoenteral tube for longer than four weeks.

References:

Manual do Paciente em terapia Nutricional Enteral Domiciliar da CGAN (Coordenação Geral de Alimentação e Nutrição), do Ministério da Saúde.

Accessed at https://www.crn8.org.br/conteudo/manual-do-paciente-em-terapia-nutricional-enteral-domiciliar/643#

http://bvsms.saude.gov.br/bvs/publicacoes/cuidados_terapia_domiciliar_v3.pdf

http://www.nutritotal.com.br/pluginfile.php/127579/mod_resource/content/3/Diten%202018.compressed.pdf

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