ENTERAL NUTRITION

1

• ENTERAL NUTRITION

2
Background

• Definition Provision of a liquid formula diet by
  tube or mouth into the GI tract.
• Feeding Access
• Formulas
• 1980s Decade of enteral

3
General Indications

• Patient who cant eat
• Patient who wont eat
• Patient who shouldnt eat
• Patient who cant eat enough
• Where there is a functional GI

4
Enteral vs. Parenteral

• Advantages of Enteral
• Safer Fewer complications
• Metabolic Dextrose Fluid and electrolyte
• Catheter Related Mechanical Septic
• However has its own unique complications
• Maintains GI Function
• TPN Loss of GI function atrophy
• Immune fuctionPrevents bacterial translocation

5
Enteral vs. Parenteral

• Advantages of Enteral
• Lower Cost
• Formula and delivery system costs
• Less patient care time
• Simpler system
• Easier for caregiver or self administration

6
Indications

• Enteral nutrition should be part of routine care
• Enteral nutrtion would usually be helpful
• Eneral nutrition is of limited or undetermined
  value
• Enteral nutrition should not be used

7
Enteral feeding should be part of routine care

• Protein-calorie malnutrition with inadequate oral
  intake for the previous 5 days
• Normal nutrition status with gt 50 required oral
  intake for the previous 7-10 days
• Severe dysphagia
• Major full-thickness burns
• Massive small bowel resection in combination with
  administration of TPN
• Low output enterocutaneous fistulas

8
Enteral feeding would usually be helpful

• Major trauma
• Radiation therapy
• Mild chemotherapy
• Liver failure and severe renal dysfunction

9
Enteral feeding is of limited or undetermined
value

• Intensive chemotherapy
• Immediate postoperative or poststress period
• Acute enteritis
• Less than 10 remaining small intestine

10
Enteral feeding should not be used

• Complete mechanical intestinal obstuction
• Severe diarrhea
• High output external fistulas
• Severe pancreatitis
• Shock
• Aggressive nutritional support not desired by the
  patient or legal guardian, in accordance with
  hospital policy and existing law.
• Prognosis not warranting aggressive nutritional
  support

11
Products

• Complete Formulas
• Modular (Supplements)
• Elemental
• Disease Specific

12
Complete formulas

• Also called meal replacements
• Intact nutrients
• One or two sources of protein, carbohydrate and
  fat
• Carbohydrate Maltodextan, hydrolyzed corn
  starch, corn syrup
• Protein Soy protein, casein
• Fat Soybean oil, canola oil, corn oil
• Vitamins RDA in 1250 2000 ml
• Minerals Na, K, MG, Phos, Ca usually trace
• With and without fiber

13
Complete formulas

• Standard feedings Approx. 1 kcal/ml
• Unflavored isotonic Jevity Osmolite
• Osmolite HN
• Flavored Ensure Sustacal
• High calorie feedings for fluid restriction
• Ensure Plus 1.5 kcal/ml
• TwoCal HN 2.0 kcal/ml
• Magnacal 2.0 kcal/ml

14
Complete formulas

• Ready to hang
• Advantages
• Less nursing time
• Less risk of food poisoning
• Can actually handle aseptically
• Various Osmolite HN, Jevity

15
Modular products

• Also called supplements
• Provides only one type of nutrient
• Given with a complete formula
• Protein ProMod, Propac
• Fat MCT oil, Safflower oil
• Carbohydrate Polycose, corn syrup

16
Elemental formulas

• Nutrients broken down
• Low fat
• MCT oil
• Examples Vivonex T.E.N. Vital HN Peptamin
  Criticare HN
• Use Malabsoption states Short bowel, fistula,
  pancreatitis

17
Disease specific formulas

• Hepatic disease
• Renal disease
• Trauma stress
• Pulmonary disease
• Diabetes

18
Hepatic disease

• Low in aromatic amino acids and methionine
• High in branched chained amino acids
• Low in amino acid concentration
• (High calorie to nitrogen ratio)
• Products Hepatic-Aid II

19
Renal disease

• Amin-Aid Suplena
• Low protein, high in essential AA
• Modified electrolytes
• Caloric dense
• Nepro higher in protein for dialysis patients

20
Trauma stress

• TraumaCal Stresstein AlitraQ
• High nitrogen
• May be high in BCAA
• Caloric dense

21
Pulmonary disease

• Pulmocare
• 55 of calories from fat
• Primarily corn oil
• Intended to decrease CO2 production

22
Diabetes

• Glucerna
• Less carbohydrate
• More fat
• Intended to improve glucose tolerance

23
Complications

• Gastric retention, emesis and aspiration
• Diarrhea
• Constipation
• Hyperglycemia

24
Gastric retention, emesis and aspiration

• Forced feeding
• May lead to aspiration pneumonia
• Prevention
• Elevate the head of the bed
• Check gastric residuals
• Hold feeding if gt 2x hourly rate and gt 100 ml
• Give promotility drug Reglan
• Transpyloric placement of feeding tube
• Two barriers to reflux of EFS
• Add green food coloring to feeding

25
Diarrhea Causes

• Feeding delivered at too high a rate
• Feeding is hyperosmolar
• Bacterial contamination of EFS
• Malabsorption/enzyme deficiency
• Medications Antacids, cholinergic drugs, broad
  spectrum antibiotics
• Pseudomembraneous colitis superinfection with C.
  difficile

26
Diarrhea Prevention Treament

• Use isotonic feedings
• Start feeding at 25 -50 ml/hr advance gradually
• Limit hang time to 6 hours or use ready to hang
  product
• Enzyme difficiency use elemental feeding
• Change medications if possible
• Check stool for C. difficile titre
• If positive treat with vancomycin or
  metronidazole
• If negative give Lomotil
• Use a product with fiber or administer Metamucil
• (Make sure the nurses know why your are giving
  it.)

27
Constipation

• Prevention use a fiber containing product
• If no BM x 3 days- give laxative
• How to turf a BM

28
Hyperglycemia

• Less frequent than with TPN
• Monitor and treat patients with glucose
  intolerance

29
Administration Techniques

• Short term access
• Long term access
• Continuous feeding
• Bolus feeding

30
Short term access

• NG (nasogastric) tube
• Made of soft silastic material
• Various sizes
• Small bore feeding tube more comfortable
• Placement verified by x-ray
• Larger bore tube (sump) check gastric
  residuals

31
Access

• Gastrostomy
• Generally preferred Less diarrhea If pulled out
  can be
• replaced larger bore tube- less clogging
• Jejunostomy Useful when there is an upper GI
  obstruction
• Small bore, more diarrhea
• PEG (percutaneous endoscopic gastrostomy
• Can avoid general surgery costs less to place
• 4 complication rate
• Small bore more likely to clog

32
Continuous vs. bolus feeding

• Continous
• Most frequent method used in hospitals and
  nursing homes
• Less nursing time
• Generally better tolerance Less diarrhea and
  emesis
• Better compliance
• Bolus
• Often used for home patients to self administer
• Costs less to administer
• Simplest to teach
• More patient freedom

33
Cyclic

• At night only to improve oral intake during the
  day
• Home patients (bedfast) Sometimes given during
  day to improve sleep