Hydration

The ability to deliver nutrition and hydration artificially is a powerful tool; in many clinical settings patient weight, nitrogen balance, visceral protein markers, and other parameters are favorably affected. While it has been difficult to document impact on survival in many clinical settings, artificial nutrition and hydration have become an essential component of multidisciplinary care in acutely ill or injured patients.

The means for providing nutrition and fluids under these circumstances are twofold. One is parenteral nutrition, called total parenteral nutrition (TPN). Fluid and nutrients are administered intravenously, most often via a large central vein accessed by a catheter placed using a minor surgical or radiological procedure. The other is enteral nutrition, in which nutrients are artificially pumped into the stomach or small intestine through a transnasal tube or ostomy (gastrostomy, jejunostomy). While nutritional goals can often be met with either method, TPN is costly and subject to complications, particularly infection. Unless precluded by medical conditions, enteral feeding is most often chosen when non-oral feeding is to be initiated.

The benefits of generally short-term nutritional support can be significant. Not surprisingly, as a result of these experiences, chronic, indefinite use of enteral feeding has been proposed for patients who have permanently lost the ability to take in adequate calories. However, the benefits of long-term enteral feeding in many settings have, for the most part, not been defined in controlled clinical trials. While observational studies with case-control or cohort design have provided insight into this area, ultimately, a decision to live with enteral tube feedings when oral intake ability has been lost or impaired becomes an individual one and personal values can be a critical variable. Advanced dementia, terminal cancer, and catastrophic neurological injury are clinical circumstances in which this option is often considered.

In the past, when long-term artificial feeding was considered, surgical gastrostomy provided enteral access. This has been largely replaced by endoscopic gastrostomy that can be performed, if necessary, at the bedside. This technique does not require general anesthesia, has less associated morbidity, and can be performed for a fraction of the cost of that for surgical techniques. Endoscopic placement, or percutaneous endoscopic gastrostomy (PEG), was first reported by Michael Gauderer in pediatric patients. It has since been adapted to many clinical situations, involving patients of all ages who are unable to eat and are thought to need nutritional support. In the Medicare population alone, PEG procedures more than doubled from 1991 to 1999, numbering more than 160,000 annually.

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