Enteral Nutrition NFSC 370 McCafferty

A. Definition: Utilization of the GI tract to supply nutrients l l l

B. Preferred over parenteral nutrition: l

C. Indications for use l § §

D. Contraindications for use l l l l l

l l l l l l l l

Types of Formulas 1. Standard/Intact/Polymeric Formulas Complete macronutrient molecules: Pt. must be able to digest/absorb nutrients l l

2. Hydrolyzed (Elemental) Formulas l Low fat or MCT l Low residue

3. Modular Formulas e.g. Polycose, Promod l l Can be added to existing enteral formula to modify its composition l Can be combined together to create a highly individualized formula (rare)

Formula Composition 1. Kcalories l Standard – l Concentrated – 2. Residue: contributes to fecal bulk l Low residue formula: 3. Fiber l Fuel:

4. Osmolality: concentration of particles in a solution (mOsm/kg) l Osmolality of blood – l Isotonic solution: l Hypertonic solution: – Cost: Standard formulas are cheapest.

Formula Selection

Routes of Administration A. Nasogastric (NG) Passage of the feeding tube transnasally into the stomach 1. Advantages a. b.

2. Disadvantages a. Potentially aspirated: b. Patient can pull out the tube c. Nose and esophagus can become irritated d. Cosmetically unattractive

B. Nasoduodenal/Nasojejunal: l Passed nasogastrically into stomach, migrate to small bowel 1. Advantages a. b.

2. Disadvantages a. b. Limits choice of formulas:

c. Increased chance of hypoglycemia (as in dumping syndrome) d. Patient can pull out the tube e. Nose and esophagus can become irritated f. Cosmetically unattractive

C. Gastrostomy (PEG, G-tube) – Endoscopically placed into stomach, then brought out through abdominal wall (PEG) or surgically placed (GT) More permanent – for use when TF will be long- term or if tube can’t be passed 2’obstruction, etc.

1. Advantages a. b. c. 2. Disadvantages a. b. c.

D. Jejunostomy (PEJ, J-Tube) 1. Advantages a. b. c. 2. Disadvantages a. Can’t recannulate if the tube comes out b. Penetrates peritoneum; source of infection

Formula Delivery ** Head of bed should be elevated 30 0 during and after TF administration to minimize risk of aspiration.

1. Bolus feeding or “meal infusion” a. b. c. d. e. f.

2. Continuous infusion a. Continuous delivery in controlled amounts over 24hours b. Controlled delivery for enhanced GI tolerance (not much difference if delivered to stomach with functioning pylorus) c. Begin isotonic formula at FS at a slow rate d.  rate as tolerance allows in stepwise increments until nutrient goals are met e. Gastric residuals

f. Gravity vs. Pump l Gravity method less accurate More attention must be paid to tube size, location, and patient mobility. Not advisable with closed system delivery l Pump – more accurate, enhances GI tolerance, more expensive

3. Cyclic feeding a. E.g. b. c. 4. All feedings: Supplemental Water a. Water used to flush feeding tube before and after feeding/when tube/bag are changed b. Pay attention to hydration status of pt. c. Total water should be d. Typical TF formula is

5. Drugs via Tube a. Can cause drug-nutrient interactions b. Formula can affect drug absorption c. Some drugs can clog tubes

Tube Feeding Complications 1. Failure to achieve/maintain adequate nutrition status a. Check calculations b. c. d. e. Monitor pt. tolerance of TF

2. Diarrhea a. May be related to formula, illness, or other treatments b. c. Bacterial contamination d. Infusion rate too high – e. Hypertonic formula – f. Malnutrition/low serum albumin – slow rate or continuous drip.

3. Aspiration 4. Nausea 5. Malabsorption 6. Clogged feeding tube 7. Fluid/lyte imbalances 8. Hyperglycemia 9. Refeeding Syndrome (to be discussed in “Stress” chapter)

Calculations 1. Caloric Requirements of Patient H-B/Long’s method or kcals/kg 2. Protein Requirements a. _____g/kg current weight (or adjusted weight ) b. Kcal:N ratio 200:1 not stress, hospitalized 150:1 moderate stress 100:1 severe stress, such as burns, sepsis, head injury

3. Water Requirements l 1ml/kcal, or 30-35ml/kg/day minimum (adults only). 4. Calculating Tube Feeding: (refer to handout)

Charting Enteral Order: Date, product, rate, strength, additional fluid, IV fluids if applicable Nutritional Provisions: Kcals, protein, and fluid provided Labs: Albumin, BUN, Na, and Glucose Nutritional Needs: Kcals, protein, and fluids (as calculated with Harris-Benedict equation, etc.) Assessment: Albumin and wt. status, hydration status, appropriateness/adequacy of enteral order, tolerance, nutrition status of patient.