8/25/2020
SPECIAL NUTRITON SUPPORT Part 1:
ENTERAL NUTRITION
As s t . P r o f . D i a n e M e n d o z a - S a r m i e n t o
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
NUTRITION SUPPORT FLOW CHART
Golden rule: If the gut is working,
USE it!
Nutrition in Clinical Practice, Volume: 33, Issue: 6, Pages: 906-920, First published: 15 October 2018, DOI: (10.1002/ncp.10204)
1
8/25/2020
Enteral
FR
(from the Greek enteron = intestine)
feeding through the gastrointestinal tract via a
tube, catheter, or stoma that delivers nutrients
distal to (or beyond) the oral cavity.
terms “enteral feeding” and “tube feeding” are
used interchangeably in the clinical setting.
Rolfes, Understanding Nutrition
Nelms, Nutrition and Pathophysiology
UNIVERSITY OF SANTO TOMAS American Dietetic Association
DEPARTMENT OF NUTRITION AND DIETETICS
FR
DEFINITION:
Supplementation or total nutrition feeding directly
into the GIT using a feeding tube.
Beneficial effect on maintenance of intestinal
structure and function.
Enhanced utilization of nutrients, ease and safety
of administration and cost efficiency.
Rolfes, Understanding Nutrition
Nelms, Nutrition and Pathophysiology
American Dietetic Association
UNIVERSITY OF SANTO TOMAS
American Society of Enteral and parenteral Nutrition
DEPARTMENT OF NUTRITION AND DIETETICS
2
8/25/2020
FR
The administration of EN provides effects which are far beyond those
of merely administering macro-micro-nutrients.
Complex response which affects body composition and
immunologic integrity.
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
EN significantly reduces the incidence of infectious complications in critically ill and
critically injured patients.
“Starving” the gut severely impairs the antiviral and antibacterial defenses, but the
defect is reversible in 3 to 5 days with enteral stimulation
EN stimulates and maintains normal immunologic defenses necessary for an intact
immunologic barrier against the external environment.
Lack of enteral feeding (with preservation of nutritional status using parenteral
feeding) interferes with this LTβR* driven control system
* important in immune development and host defense,
maintain the homeostasis of CD4+ myeloid dendritic cells within lymphoid organs
3
8/25/2020
ASPEN GUIDELINES FOR USE OFFR
EN:
patients with PEM with inadequate oral intake for the previous 5 days;
With < 50% of required needs for the previous 7 to 10 days
Severe dysphagia
Major full thickness burns
Short gut
Psychiatric/eating disorders
Impaired swallowing
Increased nut’l losses (sepsis)
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
ASPEN GUIDELINES FOR USE OF EN:LIMITED OR UNLIMITED VALUE
Px receiving intensive therapy;
Px with acute enteritis secondary to radiation, acute
infection or active inflammatory bowel disease;
Px with <10% remaining small intestines
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
4
8/25/2020
FR
ASPEN GUIDELINES FOR USE OF EN: CONTRAINDICATION
Px with complete or small bowel obstruction;
Px with ileus or intestinal hypomotility
Px with severe diarrhea resistant to pharmocologic tx
Severe pancreatitis
Shock
Gastrointestinal bleeding
Legal matters
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
ACCESS
5
8/25/2020
ROUTES
FR
Nasogastric -not at risk for aspiration and vomiting
Naso doudenal/naso gastric -at risk for aspiration
Ostomies; gastrostomy, jejunostomy -if the FDG will be more than a
month
*Some my be done through surgery or percutenous endoscopy
Rolfes, Understanding Nutrition
Nelms, Nutrition and Pathophysiology
UNIVERSITY OF SANTO TOMAS American Dietetic Association
DEPARTMENT OF NUTRITION AND DIETETICS
FR
Summary of Enteral Access Sites:
SITE INDICATIONS ADVANTAGES DISADVANTAGES
NASOGASTRIC normal GI function uses and stimulate GI aspiration
flexibility in administration discomfort
medications can be placed nasal irritation
tube insertion at bedside tube displacement
NASODUODENAL normal small intestine tube insertion at bedside discomfort
need to bypass stomach tube displacement
NASOJEJUNAL normal small intestine tube insertion at bedside discomfort
need to bypass stomach tube displacement
Rolfes, Understanding Nutrition
Nelms, Nutrition and Pathophysiology
American Dietetic Association
UNIVERSITY OF SANTO TOMAS
American Society of Enteral and parenteral Nutrition
DEPARTMENT OF NUTRITION AND DIETETICS
6
8/25/2020
FR
Summary of Enteral Access Sites:
SITE INDICATIONS ADVANTAGES DISADVANTAGES
GASTROSTOMY normal GI funx. Long term feeding access surgical procedure
bypass the upper GI reduced risk of displacement irritation
allows bolus feeding Infection on site
PEG normal GI outpatient procedure irritation and
bypass the upper GI long term feeding access infection
less expensive; reduced risk
for tube displacement
JEJUNOSTOMY normal GI function increased tolerance for early surgical procedure
but need to bypass initiation of EN risk for irritation
components of GI tract and infection, risk of
clogging may be greater
Rolfes, Understanding Nutrition
Nelms, Nutrition and Pathophysiology
American Dietetic Association
UNIVERSITY OF SANTO TOMAS
American Society of Enteral and parenteral Nutrition
DEPARTMENT OF NUTRITION AND DIETETICS
FR
Formula Selection:
Rolfes, Understanding Nutrition; page 641
7
8/25/2020
FR
TYPES OF FORMULA:
POLYMERIC
composed of intact proteins, disaccharide
and polysaccharides variable amounts of fat, residue
and lactose.
osmolality of polymeric formulas is usually lower than
the osmolality of “elemental” formulas.
In general, these formulas require a functioning
gastrointestinal tract for digestion and absorption of
nutrients.
Nelms, Nutrition and Pathophysiology
American Dietetic Association
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
TYPES OF FORMULA:
PREDIGESTED/HYDROLYZED
composed of low molecular weight nutrients
minimal residue are thought to lead to less stimulation of
pancreatic and gastrointestinal secretions
less allergenic than other formula.
Nelms, Nutrition and Pathophysiology
UNIVERSITY OF SANTO TOMAS American Dietetic Association
DEPARTMENT OF NUTRITION AND DIETETICS
8
8/25/2020
FR
TYPES OF FORMULA:
MODULAR
individual micronutrient modules
such as glucose polymers, protein,
or lipids are available as additives
to food and enteral formulas to
change overall fuel composition.
Nelms, Nutrition and Pathophysiology
American Dietetic Association
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
TYPES OF FORMULA:
SPECIAL DISEASE-SPECIFIC
these products are designed
for patients who have specific
medical conditions that may
require nutrient modification.
Elemental: supplemented with additional amounts of
specific amino acids such as glutamine or arginine.
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
9
8/25/2020
FR
TYPES OF FORMULA:
DIETARY FIBER
Fiber-containing enteral formulas are most viscous and
may require a larger diameter feeding tube for adequate
flow.
Nelms, Nutrition and Pathophysiology
UNIVERSITY OF SANTO TOMAS
American Dietetic Association
DEPARTMENT OF NUTRITION AND DIETETICS
FR
Formula Selection: Osmolality
• Refers to the moles of osmotically active solutes per kg solvent
• Measure of the oncotic pressure exerted by a solution;
What determines osmolality?
•Number and
•Size of : electrolytes, CHO; minerals; CHON
Factors that can increase osmolality?
•Concentration of formulas; (energy:volume)
•Addition of modular products
Formulas with higher osmolality may induce the shift of free water into the intestinal space;
thus may cause rapid transit diarrhea.
Nelms, Nutrition and Pathophysiology
American Dietetic Association
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
10
8/25/2020
FR
Open Feeding system: formulas are transferred from original
container
Closed feeding system: administered directly form the
prepackaged container (ex: RTH)
Administration:
Continuous feeding –constant, steady rate over a 16-
24 hour period (or more), feeding pump
Cyclic Feeding – delivered by continuous drip method
at an increased rate over 8 to 16 hours, feeding pump
Intermittent feeding- can be infused at specific
intervals throughout the day, 20-60 minutes, gravity or
pump assist
Bolus feeding- rapid administration of feeding, 4-10
minute
Rolfes, Understanding Nutriton
UNIVERSITY Ichimaru
OF SANTO TOMAS
S. Methods of Enteral Nutrition Administration in Critically Ill Patients: Continuous, Cyclic, Intermittent, and Bolus Feeding. Nutr Clin Pract. 2018;33(6):790-795. doi:10.1002/ncp.10105
DEPARTMENT OF NUTRITION AND DIETETICS
FR
Initiation and Special Considerations
INITIATION
can be started at 10-40 (50) ml/hr, then progress until desired rate.
50 mL/hr then add 25 mL as desired rate is achieved (Continuous)
125 then increase by 125 mL until final volume is achieved (Bolus)
CONSIDERATIONS:
•Temperature
•Bacterial Contamination
•Prevention of aspiration
American Dietetic Association
•Medications American Society of enteral and Parenteral Nutrition
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
11
8/25/2020
FR
Complications: Gastrointestinal
•Diarrhea
•Hyperosmolar formula
•Malabsorption
•Bolus feeding, volume overload, rapid administration
•PEM
•Hypoalbuminemia
•Medications
•Nausea or vomiting
•Constipation
•“coffee ground”
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
Complications: Mechanical
• Mechanical Problems:
•Occlusion or clogging of the tube
•Misplacement of the tube
•Skin irritation around ostomy site
•Metabolic problems
•Electrolyte and metabolic abnormalities
•dehydration
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
12
8/25/2020
FR
Termination of Tube Feeding
•Gradual weaning;
•Increased oral intake
•Decreasing the volume of the formula
•can eat/drink the formula that was earlier on the tube
•Monitor oral intake.
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
Monitoring:
•Tube placement
•Daily weight
•Intake and output
•CBG (DM, px w/ steroids)
•Gastric residuals (esp. if high risk for aspiration)
•Bowel movements and consistency
•Feeding tolerance
•Electrolytes
•Baseline and weekly reassesment of [Link] with appropriate adjustments
•Daily feeding tube site care
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
13
8/25/2020
EN Computations FR
Natural
Mixed (Natural + Formula)
Formula
Diet Prescription
Start at: 22 kcal/kgbw, 1.5 grams CHON, 60%-40%
CHO-FAT, 1.5 kcal: 1 mL, continuous feeding (pump
assisted, 24 hrs)
Progress to: 30 kcal/kgbw/day, 1.5 grams CHON,
BMI: 18.5 kg/m2, Had significant
60%-40% CHO-FAT, 1 kcal: 1 mL, intermittent
weight loss, inadequate intake (<55%)
feeding every 4 hours
Actual body weight: 52 kg
Screening: high risk for malnutrition
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
FR
Sample Computation
Diet Prescription
Start at: 22 kcal/kgbw, 1.5 grams CHON, 60%-40% CHO-FAT, 1.5 kcal: 1 mL, continuous
feeding (pump assisted, 24 hrs)
1,144 kcal, 125g CHO, 78g CHON, 37g FAT, 763 mL (750mL @ 31 mL/hr)
Progress to: 30 kcal/kgbw/day, 1.5 grams CHON, 60%-40% CHO-FAT, 1 kcal: 1 mL,
intermittent feeding every 4 hours
1,560 kcal, 187g CHO, 78g CHON, 55g FAT, 1560 mL (@260mL x 6 feeds)
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
14
8/25/2020
FR
Natural
Food Item Exchanges CHO CHON Fats (g) Kcal Practice Food safety
(g) (g) Have separate utensils
for feeding preparation
Vegetables Have designated space
(as possible)
Fruit Food items: tender, well
Milk, low Fat cooked, blenderized
Strain as necessary
Keep refrigerated
Rice May be prepared at one
time or several times a
Meat/EW day*
Discard leftover mixture
Fats May consider lactose
Total free alternative (milk)
Avoid adding sugar
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
ENTERAL FORMULA
FR
Enteral Formula Grams/ 1 SCOOP
scoop
CHO PRO FAT KCAL
En-Plus 9 5.6 1.44 1.27 37.72
Boost Optimum 7.6 4.2 1.4 1.4 36
Nutren Diabetes 8 4.59 1.57 1.81 40.93
Glucobest 13 6.25 2.5 2.12 57.25
Diabetasol 15 9.75 2.5 1.75 65
Peptamen 7.9 4.81 1.55 1.51 39.08
Alitraq 76 g 48.75 15.75 4.33 300
(sachet)
Beneprotein 7 0 6.0 0 25
Glucerna SR 8.9 4.84 1.83 1.33 36.76
Prosure 8.3 4.39 1.76 0.68 33.4
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
15
8/25/2020
ENTERAL FORMULA
FR
UNIVERSITY OF SANTO TOMAS
Add a footer 34
DEPARTMENT OF NUTRITION AND DIETETICS
FORMULA
FR
1,144 kcal, 125g CHO, 78g CHON, 37g FAT, 763 mL (750mL @ 31 mL/hr)
Formula: # of Scoops CHO (g) CHON (g) Fats (g) Kcal
Ensure 24 124.8 33.84 30 905.28
78 grams 37 grams
-33.84g -30 g
44 grams 7 grams
Beneprotein 7 42 175
Oil 1 5 45
Total: 125 76 35 1,125.28
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
16
8/25/2020
FR
FORMULA-NATURAL
1,144 kcal, 125g CHO, 78g CHON, 37g FAT, 763 mL (750mL @ 31 mL/hr)
Formula: # of Scoops/ CHO (g) CHON (g) Fats (g) Kcal
exchanges
Ensure 14 72.8 19.74 17.5 528
Veg 2 6 2 - 32
Bread 2 46 8 -
216
Meat (LF) 6 48 6 246
Oil 3 15 135
UNIVERSITY OF SANTO TOMAS
DEPARTMENT OF NUTRITION AND DIETETICS
.
.
UNIVERSITY OF SANTO TOMAS
37
DEPARTMENT OF NUTRITION AND DIETETICS
17
8/25/2020
Formula based: 1,600 kcal, EN divided to 6 EF, 1:1 dilution, Diabetic
Formula: # of Scoops CHO (g) CHON (g) Fats (g) Kcal
Practice
UNIVERSITY OF SANTO TOMAS
39
DEPARTMENT OF NUTRITION AND DIETETICS
ASSESS the dietary intake (Calorie/CHON Counting):
22 kcal/kgbw, 1.5 grams CHON, 60%-40% CHO-FAT, 1.5 kcal: 1 mL, continuous feeding (pump assisted,
24 hrs)
Diet Prescription: 1,144 kcal, 125g CHO, 78g CHON, 37g FAT, 763 mL (750mL @ 31 mL/hr)
Total Volume given via continuous feeding (24 hours): 570 mL
_____ kcal ____ % Adequacy
_____ g CHO ____ % Adequacy
_____ g CHON ____ % Adequacy
_____ g FAT ____ % Adequacy
Practice
UNIVERSITY OF SANTO TOMAS
40
DEPARTMENT OF NUTRITION AND DIETETICS
18
8/25/2020
1,560 kcal, 187g CHO, 78g CHON, 55g FAT, 1560 mL (@260mL x 6 feeds)
Formula: # of Scoops CHO (g) CHON (g) Fats (g) Kcal
Feeding schedule and number of scoops per feed:
Example: 6 AM 5 scoops ensure + 2 scoops beneprotein
4 AM ___________________________
8 AM ___________________________
12 noon ___________________________
4PM ___________________________
8 PM ___________________________ Practice
12 MN ___________________________
UNIVERSITY OF SANTO TOMAS
41
DEPARTMENT OF NUTRITION AND DIETETICS
ASSESS the dietary intake (Calorie/CHON Counting):
Progress to: 30 kcal/kgbw/day, 1.5 grams CHON, 60%-40% CHO-FAT, 1 kcal: 1 mL, intermittent
feeding every 4 hours
Diet Prescription: 1,560 kcal, 187g CHO, 78g CHON, 55g FAT, 1560 mL (@260mL x 6 feeds)
Feeding Intake/flushing:
4 AM 180 mL/ 20 mL 4 PM 250 mL/30 mL
8 AM 200 mL/20 mL 8 PM 260 mL/30 mL
12 nn 200 mL/20 mL 12 MN 150 mL/20 mL
_____ kcal ____ % Adequacy
_____ g CHO ____ % Adequacy
_____ g CHON ____ % Adequacy
_____ g FAT ____ % Adequacy
Practice
UNIVERSITY OF SANTO TOMAS
42
DEPARTMENT OF NUTRITION AND DIETETICS
19
8/25/2020
You can do it!
I am here with you ;)
UNIVERSITY OF SANTO TOMAS
43
DEPARTMENT OF NUTRITION AND DIETETICS
20
