A patient presents in coma for 20 days, what will be the best way to give him nutrition?
ANSWER: (C) Feeding via jejunostomyREF: European Journal of Anaesthesiology: January 1998 - Volume 15 - Issue - pp 94-96Oral feeding is rarely applicable to comatose patients. Early enteral (EN) nutrition through a nasoduodenal or nasojejunal tube will overcome the problem of delayed gastric emptying. Patients requiring enteral feeding on a long-term basis should have a gastrostomy or gastrojejunostomy tube placed,Parenteral nutrition (PN) is indicated when a patient's gastrointestinal tract does not tolerate full enteral feeding or when the access to the GI tract is difficult after head and neck trauma. Parenteral nutrition may be administered as central venous nutrition (expected duration of PN > 7 days) or as peripheral venous nutrition (short-term PN < 7 days).(Note: When GI tract is healthy, use it) Sabiston Textbook of Surgery, 18th ed.OPTIONS FOR ENTERAL FEEDING ACCESSAccess OptionCommentsNasogastric tubeShort-term use only (<30 days); aspiration risks; nasopharyngeal trauma; frequent dislodgmentNasoduodenal/nasojejunal tubeShort-term use (<30 days); lower aspiration risks in jejunum; placement challenges (radiographic assistance often necessary)Percutaneous endoscopic gastrostomy (PEG)Endoscopy skills required; may be used impaired swallowing mechanisms, oropharyngeal or esophageal obstruction, and major facial trauma; aspiration risks; can last 12-24 months; slightly higher complication rates with placement and site leaksSurgical gastrostomyRequires general anesthesia and small laparotomy; procedure may allow placement of extended duodenal/jejunal feeding ports; laparoscopic placement possibleFluoroscopic gastrostomyBlind placement using needle and T-prongs to anchor to stomach; can thread smaller catheter through gastrostomy into duodenum/jejunum under fluoroscopyPEG-jejunal tubeJejunal placement with regular endoscope is operator dependent; jejunal tube often dislodges retrograde; two-stage procedure with PEG placement, followed by fluoroscopic conversion with jejunal feeding tube through PEGDirect percutaneous endoscopic jejunostomy (DPEJ)Direct endoscopic tube placement with enteroscope; placement challenges; greater injury risks. Used in patients who cannot tolerate gastric feedings or who have significant aspiration risksSurgical jejunostomyCommonly carried out during laparotomy; general anesthesia; laparoscopic placement usually requires assistant to thread catheter; laparoscopy offersFluoroscopic jejunostomydirect visualization of catheter placementDifficult approach with injury risks; not commonly doneINDICATIONS OF PARENTERAL NUTRITION:Schwartz's Principles of Surgery 9th edition chapter 2 SystemicResponse to Injury and Metabolic Support1. Newborn infants with catastrophic gastrointestinal anomalies, such as tracheoesophageal fistula, gastroschisis, omphalocele, or massive intestinal atresia2. Infants who fail to thrive due to gastrointestinal insufficiency associated with short-bowel syndrome, malabsorption, enzyme deficiency, meconium ileus, or idiopathic diarrhea3. Adult patients with short-bowel syndrome secondary to massive small-bowel resection (<100 cm without colon or ileocecal valve, or <50 cm with Intact ileocecal valve and colon)Patients with enteroenteric, enterocolic, enterovesical, or high-output enterocutaneous fistulas (>500 mL/d)Infants who fail to thrive due to gastrointestinal insufficiency associated with short-bowel syndrome, malabsorption, enzyme deficiency, meconium ileus, or idiopathic diarrheaPatients with normal bowel length but with malabsorption secondary to sprue, hypoproteinemia, enzyme or pancreatic insufficiency, regional enteritis, or ulcerative colitisAdult patients with functional gastrointestinal disorders such as esophageal dyskinesia after cerebrovascular accident, idiopathic diarrhea, psychogenic vomiting, or anorexia nervosaPatients with granulomatous colitis, ulcerative colitis, or tuberculous enteritis in which major portions of the absorptive mucosa are diseasedPatients with malignancy, with or without cachexia, in whom malnutrition might jeopardize successful use of a therapeutic optionPatients in whom attempts to provide adequate calories by enteral tube feedings or high residuals have failedCritically ill patients wfio are hypermetabolic for > 5 days or for whom enteral nutrition is not feasible
Parenteral nutrition
Ryle's tube feeding
Feeding via jejunostomy
Oral feeding
Fluid & Electrolyte