ENTERAL NUTRITION

MEETING NUTRIENT NEEDS

Selection of Feeding Route

Page 536, Krause – Figure 23-1 Algorithm or Decision Tree

– Adequate oral intake– Oral intake + supplements– Enteral nutrition support

• Patient’s medical status

• Anticipated duration of tube feeding

• Risk for aspiration

• Advantages and disadvantages of access route

Enteral Formula Selection

Selection Algorithm: Page 538, Krause – Figure 23-3

Feed as close to the farm as possible: e.g. the most intact formula the patient will tolerate

Intact nutrient, general purpose formulas are the least expensive and may be more physiological

Enteral Formulary

– What products are available?

– More cost effective to have formulary

– Include multiple products, one main brand of each category

Where can you get information about enteral products?

Nutrition Care Manual formulary page http://nutritioncaremanual.org/universi13 Novartis Nutrition USA

http://www.novartisnutrition.com/us/home Abbot Nutrition Product Handbook http://

abbottnutrition.com/productHandbook/default.asp

Nestle Nutrition http://www.nestleclinicalnutrition.com/

Nutrition Care Manual FormularyYou can View compositional information about adult

and pediatric formulas Calculate nutrient delivery based on volume Compare two formulas in the same category BUT: be aware that the most reliable and up

to date source of information about a formula is from the mfr.

Enteral Selection

Blenderized– Compleat or homemade (CAUTION!)

Standard Isotonic– Osmolite, Nutren, Isosource

Added fiber– Jevity, Impact with Fiber, Nutren with Fiber, – Nutren Replete with Fiber, Nutren 1.5 Fiber,

Fibersource, Fibersource HN,

Enteral Selection

Extra calories/volume restricted– Osmolite 1.2, TwoCal HN, Novasource 2.0,

Nutren 1.5, Nutren 2.0, Peptamen 1.5, Jevity 1.2, Jevity 1.5

High nitrogen– Osmolite HN, TwoCal HN, Fibersource HN,

Peptamen VHP, Isosource HN

Enteral Selection

Disease specific– Diabetes: Resource Diabetic, Diabetisource,

Glucerna Select– Pulmonary: Nutren Pulmonary, Pulmocare,

Novasource Pulmonary, Oxepa– Renal: Novasource Renal, Nepro, Suplena,

Nutren Renal– NutriHep (liver disease)– Prosure (cancer)

Enteral Formula Selection

Trauma/Critical Care: Traumacal, Perative, Impact, Alitraq, Oxepa, Promote, Pivot

Wound Healing: Isosource VHN, Replete, Promote, Juven (oral)

Enteral Selection Peptide based

– Peptamen, Vital, Crucial, Optimental, Vital HN, Perative, Peptinex DT, Alitraq

Free Amino Acids– Vivonex varieties, f.a.a.

Modulars– Beneprotein Instant protein powder – Benefiber– Polycose, Benecalorie, Moducal– MCT oil, Microlipid

Pediatric (ages 1-10)

Standard: Resource Just For Kids, Pediasure, Compleat Pediatric, Nutren Jr

Fiber: Resource Just for Kids w/ Fiber, Pediasure with Fiber, Nutren Jr/Fiber

Elemental: Vivonex Pediatric, Petamen Jr, Pediatric Peptinex DT

Infants: Appropriate infant formulas are used for infants

Enteral Selection

Substrates– CHO, protein, fat: consider pt’s ability to digest, absorb

nutrients

Elemental vs intact formulas– Use products with MCTs if unsure of ability to digest

fats

– Peptides may be used as well as aa’s for most

Tolerance factors– Osmolality, calorie and nutrient densities, residue

content, etc.

Physical Properties of Enteral Formulas

Osmolality– GI emptying– Retention– Nausea

Residue Viscosity

– Size of tube is important

Osmolality– GI emptying– Retention– Nausea

Residue Viscosity

– Size of tube is important

– Vomiting

– Diarrhea

– Dehydration

– Vomiting

– Diarrhea

– Dehydration

Copyright © 2000 by W. B. Saunders Company. All rights reserved.

Osmolarity vs Osmolality

Osmolarity – Measure of osmotically active particles per liter

of solution

Osmolality *– Measure of osmotically active particles per kg

of solvent in which particles are dispersed– milliosmoles of solute per kg of solvent

(mOsm/kg)

Osmolality

Isotonic formula = osmolality ~300 mOsm Body attempts to restore the 280 – 300 mOsm Enteral feedings range from < 300 – 700

mOsm/kg Formulas with high osmolality may cause shift of

water into intestinal space = rapid transit, diarrhea Medications tend to be hypertonic, particularly

elixirs; may need to be diluted to decrease hypertonicity when given via tube

Lower Osmolality

Large (intact) proteins Large starch molecules

Higher Osmolality

Hydrolyzed protein or amino acids Disaccharides Smaller particles

Osmolality of Selected Liquids/ Medications

Liquid or Drug mOsm/kg

EN formulas 250 to 710

Milk 275

Sodas 695

Juices ~990

Ice Cream 1150

Acetominophen elixir 5400

Diphenoxylate suspension 8800

Chloral hydrate 4400

Metoclopromide 8350

Meeting Nutrient Needs

Calculate kcal, protein, fluid, and nutrient needs according to age, sex, medical status

Select appropriate formula based on nutritional needs, feeding route, and GI function

Estimation of Energy Needs

• Indirect calorimetry: the gold standard, particularly with critically ill, obese, pts who do not respond well to treatment

• Most clinicians use standard energy estimation equations to estimate calorie needs

In-Class Use of Predictive Equations for EEE and REE Use actual body weight in calculations in

class Use Mifflin-St. Jeor plus activity factors, if

applicable, in ambulatory patients Use Harris-Benedict x injury factor with

actual weight in hospitalized, stressed patients. Do not use activity factor unless patients are in rehab or unusually active.

ADA Nutrition Care Manual, www.nutritioncaremanual.org, accessed 1-06

In-Class Use of Predictive Equations for EEE and REE Use 1992 Ireton-Jones in patients with

burns and trauma where Penn State data not available

Use Penn State equation in the ICU where minute ventilation and temperature are available

In-Class Use of Predictive Equations for EEE/REE In calculating protein needs, use actual

weight, but use the lower end of ranges for persons with Class I obesity or above.

It’s always best to estimate a range of needs, which reflects the imprecision of the tools available for our use.

Quick Method

Use 25-35 kcal/kg in hospitalized non-obese patients

FAO-WHO. Energy and protein requirements. Geneva: WHO, 1985. Technical report series 724.

Use 20-21 kcal/kg actual body weight in obese patients (BMI>30)

Amato P, Keating KP, Querica RA, et al. Formulaic methods of estimating caloric requirements in mechanically ventilated obese patients: a reappraisal. Nutr

Clin Pract 1995; 10:229-230.

Meeting Nutrient Needs

Enteral Formulas – caloric density:– 1.0-1.2 kcal/ml– 1.5 kcal/ml– 2.0 kcal/ml– Energy and nutrient concentration affect

volume needed• 1 kcal/mL = standard formula

• 1.5-2 kcal/mL = volume limitations

Protein

0.8 – 1.0 g/kg for maintenance 1.25 for mild stress 1.5 for moderate stress 1.75 – 2.0 for severe stress, trauma, burns

– Escott-Stump. Nutrition and Diagnosis-Related Care. 5th edition. P. 694

Or use University of Akron Assessment standards

Protein (continued)

Protein (N = gm pro ÷ 6.25)– Based on Kcal intake (NPC:N)– Normal = 200-300:1– Anabolism = 150:1– Protein malnutrition = 100:1– Critical illness = 150-200:1– Energy malnutrition = >200:1

Vitamins and Minerals

Vitamins and minerals– Determine if DRIs for v/m can be met with

calculated volume– Remember that DRIs are set for healthy people– May need to add v/m supplement

• liquid drops thru tube

• crushed pill (CAUTION!)

Fluid NeedsBased Upon Method

WeightHoliday-Seger Method

100 ml/kg BW 1st 10 kg

50 ml/kg BW next 10 kg

20 ml/kg BW/kg above 20 kg

Weight and age 16-30 years, active: 40 ml/ kg BW

20-55 years: 35 ml/kg BW 55-75 years: 30 ml/kg BW

Energy needs 1 ml/kcal estimated energy needs or 30-35 ml/kg body weight

Food and Nutrition Board, NAS, Recommended Dietary Allowances 10th Editiion, 1989; Charney and Malone, ADA Pocket Guide to Nutrition Assessment, 2004, p. 166

Meeting Fluid Needs in Enterally-Fed Patients Water in Enteral Products

– Calculate free water:• 1kcal/ml = ~85% free water (850mL per 1,000 mL

formula)

• 1.2-1.5 kcal/mL = 69% - 82% (690-820)

• 1.5-2.0 kcal/mL = 69% - 72% (690-720)

• Exact water content on label or in manufact’s info

– Subtract amt. free water from needs– Provide additional water via flushes

Meeting Fluid Needs in Enterally Fed Patients Water Flushes

– Irrigate tube q 4 hrs with 20-60 mL water with continuous feeds

– Irrigate tubes before and after each intermittent or bolus feed with 20-60 mL water

– In case of clogging, tube should be flushed using 60mL syringe with 30-60 mL warm water

– Use smaller vol for fluid-restricted pts

Meeting Fluid Needs in Enterally-Fed Patients Water

– Increase fluids as tolerated to compensate for losses:

• fever or environmental temp• increased urine output• diarrhea/vomiting • draining wounds • ostomy output, fistulas• increased fiber intake, concentrated or high-

protein formulas

Enteral Nutrition Monitoring

Wt (at least 3 times/week) Signs/symptoms of edema (daily) Signs/symptoms of dehydration (daily) Fluid I/O (daily) Adequacy of intake (at least 2x weekly) Nitrogen balance: becoming less common

(weekly, if appropriate)

Enteral Nutrition Monitoring

Serum electrolytes, BUN, creatinine (2 –3 x weekly)

Serum glucose, calcium, magnesium, phosphorus (weekly or as ordered)

Stool output and consistency (daily)

Enteral Feeding Tolerance

Signs and symptoms: —Consciousness

—Respiratory distress

—Nausea, vomiting, diarrhea

—Constipation, cramps

—Aspiration

—Abdominal distention

Monitoring Gastric Residuals

Performed by inserting a syringe into the feeding tube and withdrawing gastric contents and measuring volume

Often a part of nursing protocols/physician orders for tubefed patients

Enteral Nutrition Monitoring: Gastric Residuals The value and method of monitoring of gastric

residuals is controversial Associated with increase in clogging of feeding

tubes Collapses modern soft NG tubes Residual volume not well correlated with physical

examination and radiographic findings There are no studies associating high residual

volume with increased risk of aspiration

Absorption/Secretion of Fluid in the GI TractAddtions (mL)

Diet 2000

Saliva 1500

Stomach 2500

Pancreas/Bile 2000

Intestine 1000

Subtractions (mL)

Colointestinal 8900

Net stool loss 100

Harig JM. Pathophysiology of small bowel diarrhea. Cited in Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18;75-85.

Enteral Nutrition Monitoring: Gastric Residuals Monitoring of gastric residuals in tubefed

pts assumes that high residuals occur only in tubefed pts

In one study, 40% of normal volunteers had RVs that would be considered significant based on current standards

For consistency, all hospitalized pts, with or without EN should have their RVs routinely assessed to evaluate GI function

Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18;75-85.

Enteral Nutrition Monitoring: Gastric Residuals Clinically assess the patient for abdominal

distension, fullness, bloating, discomfort Place the pt on his/her right side for 15-20 minutes

before checking a RV to avoid cascade effect Try a prokinetic agent or antiemetic Seek transpyloric access of feeding tube Raise threshold for RV to 200-300 mL Consider stopping RV checks in stable pts

Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18;75-85.