Prescribing Regimens of Feeding Jejunostomy

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    PRESCRIBING REGIMENS OF FEEDING

    JEJUNOSTOMY

    RUPESH KUMAR

    PGT,DEPT OF SURGERYMEDICAL COLLEGE, KOLKATA

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    Definition

    Enteral nutrition: the provision of nutrients

    into the gastrointestinal tract through a tube

    or catheter when oral intake is inadequate.Also it may include the use of formula as oral

    supplements or meal replacement.

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    Principles of Enteral

    Feeding

    Stomach Principal defense against an

    enteralosmotic

    load.

    SI - Principal area for nutrient absorption.

    Hyperosmolar solutions invites morecomplications.

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    Routes for administration of

    enteral feeding

    Nasoenteric and postpyloric feeding.

    Gastrostomy

    Jejunostomy

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    An approach to feeding

    advancement Position of the patient

    For gastric feeding- first osmolality then

    volume is increased. Feeding started at the @ 10-20mL/hr

    Gastric volumes checked every 4-6 hrs

    If less

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    For SI feeding- volume is increased first thenthe osmolality (

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    Rationale for enteral nutrition

    Low cost

    intestinal mucosal atrophy.

    infection complications & acute phaseprotein production

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    Which patient is eligible for

    nutrition support ?Enteral nutrition

    Should be used in Pt. who have at least 2-3 ft

    of functional gastrointestinal tract. Who are or will become malnourished.

    In whom oral intake is inadequate to restore

    or maintain optimal nutritional status.

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    General Indications:

    The pts premorbid state Poor nutritional status

    Significant weight loss

    Duration of starvation > 7 days Anticipated duration of artificial nutrition >7days

    The degree of anticipated insult, surgical/ otherwise

    Serum albumin< 3gm%,transferrin

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    ENTERAL FORMULA COMPOSITION

    Formulas classified in a variety of ways, usuallybased on protein or overall macronutrientscomposition.

    General purpose formulas are tolerated by mostpatients and most of these formulas provide

    1kcal / ml.

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    General formulas that provide 1.5 to 2 kcal / ml

    are used to restrict fluid for patients withcardiopulmonary, renal & hepatic failure.

    High nitrogen formulas used for patients withburns, fistulas, sepsis or trauma.

    Disease specific formulas for patients with

    renal, hepatic or cardiopulmonary disease,metabolic stress,immunosuppression, or glucoseintolerance.

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    ENTERAL FORMULA CATEGORIES

    Generalpurpose / intact

    (polymeric)

    * Use in patients with normal digestion and absorption.

    * Contain intact protein.

    * Instituted at full strength ; low viscosity; 300-500 mOsm / kg.* Provide 1-2 kcal / ml.

    * Lactose free.

    * 30-40 gm protein / L.

    Defined /

    hydrolyzed(monomeric)

    Use in patients with GI compromise.

    (hydrolyzed nutrients to improve digestion). Osmolality depends on hydrolysis.

    Provide 1-2 kcal / ml.

    Lactose free.

    30-45 gm protein / L.

    Also known as chemically defined, peptide based and elemental formula.

    Semielemental use in patients with limited GI function. contains free amino acids, minimal fat and minimal residue.

    hyperosmolar and low viscosity.

    provide 1 kcal / ml.

    40 gm protein / L.

    Also known as free amino acid formula.

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    ENTERAL FORMULA CATEGORIES

    (CONT.)

    Disease specific Designed for specific organ dysfunction or metabolic disorder. May not nutritionally complete.

    Most are hyperosmolar.

    Redehydration For patient requiring an optimal ratio of simple carbohydrate toelectrolytes for the purpose of maximizing fluid and electrolyteabsorption and rehydration.

    Modular Formula providing protein, fat or carbohydrate as single nutrientsto alter the nutrient composition of commercial formulas or food.

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    ADMINISTRATION

    The three common methods of tube feeding

    administration are :

    1. Bolus feeding: infusion of up to 5oo ml of enteralformula over 5 to 20 mins by large-bore syringe .

    2. Intermittent drip feeding: administered of enteral

    feeding at specified times throughout the day;generally in smaller volume and at a slower rate

    than a bolus feeding but in large volume and

    faster rate than continuous feeding.

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    3. Continuous drip feeding: administered ofenteral formula into the gastrointestinal tract

    via pump, usually over 8 to 24 hours of day.

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    Products

    Complete Formulas

    Modular (Supplements)

    Elemental Disease Specific

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    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

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    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

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    Elemental formulas

    Nutrients broken down

    Low fat

    MCT oil Examples: Peptamin; Criticare HN

    Use: Malabsoption states: Short bowel,

    fistula, pancreatitis

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    Disease specific formulas

    Hepatic disease

    Renal disease

    Trauma & stress Pulmonary disease

    Diabetes

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    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

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    Renal disease

    Amin-Aid; Suplena

    Low protein, high in essential AA

    Modified electrolytes Caloric dense

    Nepro higher in protein for dialysis patients

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    Trauma & stress

    TraumaCal; Stresstein; AlitraQ

    High nitrogen

    May be high in BCAA Caloric dense

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    Pulmonary disease

    Pulmocare

    55% of calories from fat

    Primarily corn oil Intended to decrease CO2 production

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    Diabetes

    Glucerna

    Less carbohydrate

    More fat

    Intended to improve glucose tolerance

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    Monitoring pts receiving

    nutritional support

    Fluid balance record, daily weighing

    Document daily calorie and N intake RFT, LFT biweekly

    Regular check ups for Phos,Ca,Mg,alb,Protein,

    Haematological indices Regular examination of route of access

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    Complications of enteral

    nutrition

    Gastrointestinal Diarrhea, nausea,vomiting, abd discomfort, bloating,regurgitation and aspiration of fluids.

    Mechanical-

    Metabolic-

    Infective-

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    Thank You