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
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.