The Guts of It All

Ask the DOC

Good nutrition is essential to growth, healing, and vitality. For a variety of reasons, some people are not able to eat. In order to receive essential nutrients, such patients require supplying the nutrients using a means that does not involve chewing or swallowing. Adequate hydration must be provided, but most people can go without nutrition for at least seven days. However, depending on the situation, nutritional support may need to be started sooner than that. While in some patients the inability to eat may be temporary, in others it may be permanent.

The preferred means of providing nutrition in these situations is via the gut, known as enteral nutrition. It is the natural way in which nutrients are absorbed and it allows the intestines to do their job. Plus, it is safer than intravenous, or parenteral nutrition, which delivers nutrients into the bloodstream. The preferred route for enteral nutrition is through the stomach. A very thin plastic tube, called a nasogastric tube, is inserted through the nose and pushed into the stomach, and liquid nutrients can be given continuously at a set rate, or provided intermittently. Occasionally, a longer tube must be used to deliver the nutrients into the second section of the small intestine, or the jejunum. These tubes are intended for short-term use, up to two or three weeks. If enteral nutrition is expected to be necessary for longer than that, tubes may be placed through the abdominal wall into the stomach or jejunum. These are known as gastrostomy and jejunostomy tubes. They are placed either surgically, endoscopically, or by a radiologist and may be kept in place for years.

If the gut is not functioning or cannot be used, perhaps due to surgery or trauma, parenteral nutrition must be used. If the need is expected to be short-term, peripheral parenteral nutrition (PPN) may be used. This can be given using a standard IV line but can only be used for a few days to a week. If longer term use is necessary, total parenteral nutrition (TPN) can provide all the nutrients a person needs. The drawback, however, is that because TPN has a large amount of carbohydrates, it can damage small veins and so must be given via large veins. This can be given using a peripherally inserted central catheter (PICC), which is inserted in the arm and threaded into a central vein near the heart. A central line, inserted through the chest wall into the subclavian vein near the shoulder, may also be used but only for a short term. For long term use, a PICC line is preferred although a tunneled catheter or port inserted through the chest may be used. Parenteral nutrition may have serious complications including bloodstream infections and mild to severe liver dysfunction. Plus, because parenteral nutrition delivers basic elements like electrolytes and amino acids, component ratios differ from patient to patient and often must be adjusted on a daily basis.

Lastly, from a legal perspective, NY State prefers life, at least for those already born. If you have a living will or health care proxy and do not wish to be placed on nutritional support, you must state that in writing on these documents. Otherwise, doctors may legally place you on it despite your wishes and those of your health care proxy.

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