1. Implementing Enteral Nutrition: Formula Selection and Administration

2. Objectives To describe the categories of enteral formulas To explain how to choose the appropriate category of enteral formula for each patient’s disease state To describe the various methods for delivering enteral nutrition and how to choose the most appropriate formula for each situation

3. Enteral Formulas: Categories Polymeric formulas – Commercial – Blenderized Oligomeric formulas Disease-specific formulas Modular formulas (concentrated protein and carbohydrate preparations)

4. Polymeric Formulas Contain intact macronutrients and require digestion: Intact proteins Polysaccharides Disaccharides Polyunsaturated fatty acids (PUFA) Medium-chain triglycerides (MCT)

5. Polymeric Formulas: Benefits of Commercial Formulas Commercial FormulasBlenderized Formulas Uniform contents Sterile Low viscosity Lactose free Defined caloric density Daily nutrient variability Non-sterile; high bacterial content and other pathogens High viscosity Does not provide adequate caloric density Gallagher-Allred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50 Sullivan MM, et al. J Hosp Infect 2001;49:268-273

6. Commercial Polymeric Formulas: Selection Features Protein, caloric density, and osmolality vary With or without added fiber Most are lactose- and gluten-free Nutritionally complete in sufficient quantities Patient must have: Functional GI tract Normal digestion Normal absorption

7. Oligomeric Formula Categories Hydrolyzed macronutrients facilitate digestion and absorption Components  Amino acids – Glutamine – Arginine  Peptides  Monosaccharides  Disaccharides Also called “elemental,” “semi-elemental,” “hydrolyzed”, or “chemically defined” formula. In: Rombeau JL, Rolandelli RH, eds. Clinical Nutrition: Enteral and Tube Feeding. 3 rd ed. WB Saunders Company; 1997  Glucose polymers  Polyunsaturated fatty acids  Medium-chain triglycerides  Vitamins and minerals

8. Oligomeric Formulas: Selection Indications for Use: Inflammatory bowel disease Pancreatic insufficiency Malabsorption Short bowel syndrome Radiation enteritis Early enteral feeding Intolerance to polymeric formula

9. Enteral Formula Selection: Disease-Specific Formulas Pulmonary disease Glucose intolerance Cancer-induced weight loss Hepatic insufficiency Critical care Renal failure HIV + /AIDS Cabre E, Gassull MA. Nutrition 1992;8:1-9.

10. Disease-Specific Formula Selection: Pulmonary Disease (Chronic) Pulmonary disease with CO 2 retention Decreased carbohydrate content Increased fat content High caloric density Intact proteins Fiber supplement Brown RO et al. Clin Phar 1984;3:152-161; Askanazi J et al. Anesthesiology 1981;54:373-377 Deitel M et al. J Am Coll Nut 1983;2:25-32

11. Disease-Specific Formula Selection: Glucose Intolerance Glucose Intolerance Diabetes mellitus – Type I – Type II Hyperglycemia associated with: – Pancreatic disease – Drug and chemical-induced – Insulin receptor abnormalities – Hormonal alterations – Genetic syndromes – Metabolic stress Cabre E, Gassull MA. Nutrition 1992;8:1-9

12. Disease-Specific Formula Selection: Glucose Intolerance Recommendations Low carbohydrate content –Monosaccharides (fructose) –Glucose polymers Increased monounsaturated fat (MUFA) Added fiber Franz MJ, et al. Diabetes Care 1994;17:490-518; J Am Diet Assoc 1994;94:504-506 Diabetes Care 1997;20:514-517

13. Disease-Specific Formula Selection: Cancer-Induced Weight Loss Cancer-Induced Weight Loss Complex metabolic syndrome - anorexia, fatigue, early satiety Significant weight loss & muscle wasting Etiology is multifactorial –Pro-inflammatory cytokines –Acute phase response –Abnormal metabolism –Proteolysis inducing factor (PIF) Cannot correct by additional calories alone Negative Prognosis & QOL

14. Disease-Specific Formula Selection: Cancer-Induced Weight Loss Recommendations High protein and Zn to build muscle Low fat to avoid early satiety Low in sucrose for better patient acceptance High in fermentable fibers Eicosapentaenoic acid (EPA) Antioxidants (vitamins A, C, E and Se) Folate and iron for anemia

15. Disease-Specific Formula Selection: Hepatic Disease Hepatic Insufficiency Altered protein metabolism and protein loss Altered carbohydrate metabolism –glucose intolerance –low hepatic glycogen stores Malabsorption of fat and fat-soluble vitamins Inability to elongate or desaturate essential fatty acids Vitamin and mineral deficiencies (e.g., B-complex and Zn) Impaired urea synthesis with hyperammonemia and hepatic encephalopathy Fluid and sodium retention Reduced appetite/oral intake and taste impairment

16. Disease-Specific Formula Selection: Hepatic Disease Recommendations High caloric density with low sodium content Moderately high calorie:nitrogen ratio High in branched chain AAs and low in aromatic AAs Non-digestible soluble fiber Long-chain fatty acids and supplemental MCT Supplemented with fat soluble vitamins, Zn, folic acid and B complex vitamins Low copper, iron, manganese content

17. Disease-Specific Formula Selection: Critical Care Types of Injury Elective surgery Minor trauma Burn Pressure ulcer Patient Conditions Sepsis Inflammatory

18. Disease-Specific Formula Selection: Critical Care Nutrient Choices Hydrolyzed or intact proteins Glutamine Arginine Taurine, Carnitine Eicosapentaenoic acid (EPA), Gamma-linolenic Acid (GLA) Antioxidants Poullain et al. JPEN 1989;13:382-386; Lacey JM et al. Nutr Rev 1990;48:297-309 Barbul A et al. Surgery 1990;108:331-337

19. Disease-Specific Formula Selection: Critical Care (Mechanical Ventilation) Lung Injury / SIRS / ARDS Eicosapentaenoic acid (EPA) Gamma-linolenic Acid (GLA) Antioxidants High caloric density No arginine supplementation Gadek J. Chest 1998;114:277S; Gadek J. Crit Care Med 1999;27:1409-1420; Pacht ER, et al. Crit Care Med 2003;31:491-500

20. Disease-Specific Formula Selection: Critical Care Arginine (a double-edged sword) Conditionally essential nutrient that enhances wound healing Supports immune system and is associated with reduced infectious complications “Giving arginine to a septic patient is like putting gasoline on an already burning fire.” - B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL

21. Disease-Specific Formula Selection: Renal Disease Acute or Chronic Renal Disease Increased BUN and creatinine Increase in serum electrolytes: – Na – K – PO 4 – Mg Kopple JD. In: Shils ME et al eds. Modern Nutrition in Health and Disease. 8 th ed. Philadelphia: Lea & Febiger; 1994:1102-1134; Blumenkranz MJ et al. Kidney Int 1982;21:849-851

22. Disease-Specific Formula Selection: Renal Disease Recommendations Protein content – Predialysis:30 g/L – Dialysis:70 g/L Low electrolyte content High caloric density Monson P, et al. J Renal Nutr 1994;4:58-77 ASPEN Board of Directors. JPEN 2002;26 Suppl 1

23. Disease-Specific Formula Selection: Advanced AIDS (with weight loss) Advanced AIDS Weight loss > 5% below normal CD 4 < 400 Serum albumin < 3.0 g/dL Opportunistic infection Diarrhea Impaired immune function Raiten DJ. Nutrition and HIV Infection. Department of Health and Human Services, Washington D.C. Grunfeld C et al. Sem Gastro Dis 1991; Kotler DP et al. Am J Clin Nutr 1985

24. Disease-Specific Formula Selection: Advanced AIDS (with weight loss) Recommendations Increased protein Low fat for improved tolerance Added fiber EPA to down regulate metabolic changes associated with cachexia Increased levels of antioxidants (beta-carotene, vitamin E, C) and B vitamins (B 6, B 12 ) Baum MK, et al. Ann N Y Acad Sci 1992;669:165-174 Raiten DJ. Nutrition and HIV Infection. Dept. of Health and Human Services, Washington D.C.

25. Enteral Formula: Selection Metabolic requirements Patient condition or status Pre-existing conditions GI function

26. Enteral Formula: Selection The physician should know the formula’s nutrient profile to meet specific patient needs Understand the clinical evidence supporting specific formula use Data obtained exclusively from animal models may or may not apply to the clinical setting

27. Enteral Formula: Oral Administration Oral Supplementation Indicated especially for patients with malnutrition or at risk for weight loss When given between meals, does not reduce intake of other foods Frequently stimulates increased intake of other foods Thickened oral supplements are useful for patients with dysphagia

28. Benefits of Oral Supplements Improvement in Oral Intake Proportional Increase Delmi M et al. Lancet 1990;335:1013-1016

29. Enteral Formula: Tube Feeding Type: Intermittent Continuous: – 24 hours / day – During part of the day or at night Infusion Method: Gravity Infusion pump Gottschlich MN, Shronts EP, et al. Defined formula diets. In: Rombeau JL, Rolandelli, eds. Clinical Nutrition: Enteral and Tube Feeding. W B Saunders; 1997; Giocon JO et al. JPEN 1992;16:525-528

30. Enteral Formula: Administration Enteral Feeding Intermittent Resembles normal feeding and digestion patterns 250-500 mL of formula Administered over 30-60 minutes 5-8 times daily

31. Enteral Formula: Administration Continuous Plan 1 Beginning:Day 1: 1000 mL over 24 hours Progress:Day 2: 1500 mL over 24 hours Day 3: final volume according to needs Plan 2 Beginning:25 mL/h (first 12 hours) Progress:50 mL/h for next 12 hours rate according to needs

32. Enteral Formula: Administration Infusion Pump Indications  Small intestine feeding  Fluid restrictions  Risk of aspiration  Need for precise flow rate  Nocturnal feeding  Infants and small children Gravity Infusion Indications  Suitable for intermittent feeding  Ambulatory patients  Gastric feeding

33. Enteral Formula: Administration Summary Intermittent feeding Continuous feeding ASPEN Board of Directors. JPEN 2002;26 Suppl 1: 34SA.

34. Summary Described the categories of enteral formulas Explained how to select appropriate formulas Described the methods of enteral nutrition administration