**5. Parenteral nutrition**

with the nursing care burden [38]. In a Cochrane review with a pooled analysis of 1,271 patients from 12 randomised controlled trials, Lipp A et al. have shown that administration of pro‐ phylactic systemic antibiotics for percutaneous endoscopic gastrostomy tube placement reduces peristomal infection rates (OR 0.36, 95% CI: 0.26–0.50) [39]. Peristomal leakage can be reduced by appropriate fixation technique and antisecretory agents. In patients with persistent leakage, the tube should be withdrawn and replaced after few days or a new tube placed at the separate site, but no attempt should be made to control the leakage with a wider tube as it may exacerbate the leakage [40–42]. Diarrhoea remains the commonest gastrointestinal side effect of enteral tube feeding [43, 44]. Addition of fibre and probiotics has shown to reduce diarrhoea in enteral feeding. In a systematic review and meta-analysis including 51 studies, 43 randomised control trials and 1,762 subjects (1,591 patients and 171 healthy volunteers), Elia M et al. have shown that fibre supplementation was generally well tolerated and the incidence of diarrhoea reduced (OR 0.68, 95% CI: 0.48–0.96; 13 randomised control trials) [45]. In a randomised double blind placebo controlled trial involving 62 patients, Heimburger DC et al. have shown that most cases of diarrhoea in tube fed patients are caused by factors extraneous to tube feeding and lactobacillus treatment did not alter the risk of diarrhoea [46]. Patients on enteral feeding are also at risk of aspiration pneumonia. There are various strategies recommended to reduce the risk of aspiration namely head end of bed elevation, gastric residual volume measurement and postpyloric feeding. In a prospective randomized study involving 38 patients in medical and surgical intensive care units, endoscopically placed feeding jejunal tube-fed patients had a lower rate of pneumonia (nil vs. 10.5%) compared to patients fed by continuous gastric tube feeding [47]. In a literature review of 45 studies including patients with neurogenic oropharyngeal dysphagia over a period of 1978 to 1989, authors were not able to derive any meaningful conclusions with regard to superiority of postpyloric feeding due to limitations of individual studies with small sample size, inconsis‐ tent definitions of aspiration, varying feeding protocols, unspecified time frames, and heter‐ ogeneous populations [48]. Monitoring enteral nutrition involves fluid electrolyte balance, weight chart, serum electrolyte and glucose measurement, and stool charting. Refeeding syndrome is characterised by electrolyte depletion, fluid shifts, and glucose derangements that occur on reinstitution of nutrition in malnourished patients [49]. Chronically malnourished patients (e.g., patients with dysphagia) are at high risk of refeeding syndrome. In a study involving 321 patients with 92 patients at risk of refeeding hypophosphataemia, Zeki S et al. has shown that refeeding hypophosphataemia is more common in enteral-fed patients compared to parenteral nutrition [50]. Gradual introduction and progression of feeding over a few days with close monitoring of fluid and electrolytes can help in the prevention and early

National Institute of Clinical Excellence (NICE) guidelines recommend that in an acute setting, if patients are unable to swallow safely or meet caloric needs orally, they should have an initial 2–4 week trial of nasogastric enteral tube feeding. Health care professionals with relevant skills and training in the diagnosis, assessment, and management of swallowing disorders should assess the prognosis and options for future nutrition support [19]. Before modifying nutritional support in a patient with dysphagia, level of alertness, need for feeding assistance, mobility,

recurrent chest infections, metabolic needs, etc. should be considered [19].

recognition of refeeding syndrome.

128 Seminars in Dysphagia

In patients with short bowel or gastrointestinal intolerance, total parenteral nutrition is required. In general, parenteral nutrition should be considered if energy intake has been, or is anticipated to be, inadequate (<50% of daily requirements) for more than 7 days and enteral feeding is not feasible. Total parenteral nutrition requires labour-intensive monitoring for infection and haemodynamic stability. Metabolic complications, such as fluid overload, hypertriglyceridemia, hypercalcemia, hypoglycaemia, hyperglycaemia, and specific nutrient deficiencies, are usually caused by overzealous or inadequate nutrient administration. Catheter-related blood-borne infection is the most common life-threatening complication in patients who receive total parenteral nutrition and is commonly caused by *Staphylococcus epidermidis* or *Staphylococcus aureus* [51]. In a study involving 331 central venous catheters used for home parenteral nutrition with a median duration of 730 days, Buchman AL et al. have demonstrated increased rates of catheter-related blood-borne infections in patients receiving lipid emulsions, obtaining blood from catheter and administering medications via the catheter [52]. The incidence of most complications associated with the use of total parenteral nutrition is reduced with careful management and supervision, preferably by an experienced nutrition support team if available [53].
