- define enteral nutrition - to explore the different types of enteral formulas that are available - describe tube feeding administration guidelines

Transcription

1 Basics of Enteral Feeding 2004 Beth Mills, MS, RD, CNSD, LDN Objectives - define enteral nutrition - to explore the different types of enteral formulas that are available - describe tube feeding administration guidelines Suggested Reading Fish and Seidner. Enteral Nutrition Support in Hark and Morrison. Medical Nutrition and Disease A case-based approach, Blackwell Science, Malden, Massachusetts, 2003, pp I. Enteral Nutrition Defined A. Enteral nutrition or tube feeding is a way of providing nutrition support via the gastrointestinal tract for patients unable to otherwise meet nutrient requirements by the oral route B. Enteral nutrition is the preferred route of nutrition support when feasible - Safer, cheaper, more physiologic, and maintains gut function and integrity in comparison to parenteral (intravenous) support - Data particularly supportive for abdominal trauma II. Types of enteral feeding catheters A. Nasogastric tube B. Nasojejunal tube C. Surgical gastrostomy tube D. PEG tube (percutaneous endoscopic gastrostomy) E. G-J and PEJ tubes (percutaneous endoscopic gastrojejunostomy and jejunostomy tubes) F. Surgical jejunostomy tube III. Tube Feeding Formulations A. Standard polymeric B. Elemental or small peptide C. Disease specific IV. Tube Feeding composition of commercially prepared formulas A. Protein Content: from 6 to 26% -can be made with casein, soy, hydrolyzed protein with added amino acids, or free amino acids alone. B. Carbohydrate Content: from 28 to 90% -can be made with starch, glucose polymers, and/or disaccharides such as sucrose. C. Fat Content: from <1% to 55%

2 -can be with long-chain triglycerides, medium chain triglycerides and fish or other specialty oils V. Standard formula composition: Protein Content: 10-15% Carbohydrate Content: % Fat content: % Some patients may require different proportions because of specific disease states such as diabetes, renal or hepatic disease. VI. Formula selection - Standard/Polymeric tube feedings require some degree of digestive and absorptive capacity - Elemental/Peptide tube feedings are recommended for patients with malabsorption, pancreatitis, short bowel syndrome and/or dysfunction. VII. Disease Specific formulations A. Glucose intolerance formula made with less % total carbohydrate content - hydrolyzed cornstarch, usually higher fat content B. Immune function formula - contain added amounts of glutamine, arginine, beta-carotene, nucleic acids and fish oil (arginine use is controversial in septic, critically ill patients) C. Hepatic dysfunction formula -increased content of high branched chain amino acids and lower concentration of aromatic amino acids, reduced sodium content, high calorie to reduce volume needed to meet nutritional needs D. Pulmonary dysfunction/ adult respiratory distress syndrome (ARDS) -altered fat contents to favor n3 fatty acids and gamma linolenic acid E. Renal dysfunction -high calorie, high protein, modified levels of electrolytes and specific alterations in vitamin and mineral content F. Trauma formulation -high protein, high calorie, some with increased branched-chain amino acid (BCAA) content, some with added glutamine, arginine, special fat blends, increased levels of copper and zinc G. Wound healing formulation -high protein and higher contents of vitamin A, vitamin C and zinc VIII. Monitoring Tube Feeding Tolerance A. Gastric residuals- volume aspirated from a feeding tube placed in the stomachshould not exceed 250 ml volume B. Abdominal distension

3 C. Diarrhea D. Constipation IX. Complications A. Gastrointestinal a. medications are leading cause for diarrhea B. Metabolic a. volume status, sugars, electrolytes C. Aspiration a. risks aged, demented, stuporous, early post-op, altered gastric motility b. elevate head of bed, check residuals, post-pyloric feeding, nasogastric decompression D. Mechanical malposition, erosion, reflux, clogging, and obstruction X. Tube feeding administration guidelines. A. Continuous pump infusion for critically ill or post-operative patients Can feed by nasogastric route in many patients. Confirm position by x-ray. In general standard formulations are well tolerated. Consider duodenal or jejunal feeding when aspiration risk is present. Start full-strength at rate of 25 cc/hr. Increase as tolerated every 6-12 hrs to goal. B. Intermittent or bolus feeding Usually 5 feedings per day every three hours Not recommended for critically ill or post-op Only use for gastric feeding Easier and less expensive for home or institutional tube feeding Infuse by gravity or pump over minutes or longer if needed Conclusions A. Use the gut if feasible. B. Nasogastric feedings are well-tolerated by most patients. C. Use standard, full-strength formulations for most patients. D. Consult dietitian for assistance. References 1. Deitch EA. The role of intestinal barrier failure and bacterial translocation in the development of systemic infection and multiple organ failure. Arch Surg 125: 403-4, Bower RH. Nutrition and immune function. Nutr Clin Practice 5: 189, Souba WW, Herkowitz K, Klimberg S, et al. The effects of sepsis and endotoxemia on gut glutamine metabolism. Ann Surg 211: 543, Houdijk AP, Rijnsburger ER, Jansen J, et al. Randomized trial of glutamine-enriched enteral nutrition on infectious morbidity in patients with multiple trauma. Lancet 352: 772-6, Daly JM, Reynolds J, Thom A, et al. Immune and metabolic effects of arginine in the surgical patient. Ann Surg 208: 512, 1988.

4 6. Daly JM, Weintraub FN, Shou J, et al. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg 221: , Kinsella JE, Lokash B, Broughton S, et al. Dietary polyunsaturated fatty acids and eicosanoids: potential effects on the modulation of inflammatory and immune cells. Nutrition 6: 45, Gottschlich MM, Jenkins M, Warden GD, et al. Differential effects of three enteral dietary regimens on selected outcomes in burn patients. JPEN 14: , Rudolph FB, Kulkarni AD, Fanslow WC, et al. Role of RNA as a dietary source of pyrimidines and purines in immune function. Nutrition 6: 45, Bower RH, Cerra FB, Bershadsky B, et al. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 23: , Atkinson S, Sieffert E, Bihari D. A prospective, randomized, double-blind controlled clinical trial of enteral immunonutrition in the critically ill. Crit Care Med 26: , Heys SD, walker LG, Smith I, et al. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: a meta-analysis of randomized controlled clinical trials. Ann Surg 229: , Zaloga GP. Immune-enhancing enteral diets: where's the beef? Crit Care Med 26: , Keohane PP, Attril A, Love M, et al. Relation between osmolality of diet and gastrointestinal side effects in enteral nutrition. Brit Med J 288: 678, Moore EE, Jones TN. Benefits of immediate jejunostomy after major abdominal trauma - a prospective randomized study. J Trauma 26: 874, Fletcher JP, Little JM. A comparison of parenteral nutrition and early postoperative enteral feeding on the nitrogen balance after major surgery. Surgery 100: 21, Skei B, Kveton V, Gil KM, et al. Branched-chain amino acids: Their metabolism and clinical utility. Crit Care Med 18: 549, Pingleton SK, Harmon GS. Nutritional management in acute respiratory failure. JAMA 257: 3094, Catldi-Belcher EL, Seltzer MH, Slocum BA, et al. Complications occurring during enteral nutrition support: a prospective study. JPEN 7: 546, Edes TE, Walk BE, Austin JL. Diarrhea in tube fed patients: feeding formula not necessarily the cause. Am J Med 88: 91, Brinson RR, Pitts WM. Enteral nutrition in the critically ill patient: role of hypoalbuminemia. Crit Care Med 17: 367, Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications - the results of a meta-analysis. Ann Surg 216: , Moore FA, Moore EE. The benefits of enteric feeding. Adv Surg 30: , Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 215: , Kudsk KA, Minard G, Croce MA, et al. A randomized trial of isonitrogenous enteral diets after severe trauma: an immune-enhancing diet reduces septic complications. Ann Surg 224: , Minard G, Kudsk KA. Nutritional support and infection: does the route matter? World J Surg 22: , Lipman TO. Grains or veins: is enteral nutrition really better than parenteral nutrition? A look at the evidence. JPEN 22: , Laasch HU, Wilbraham L, Bullen K, et al. Gastrostomy insertion: comparing the options PEG, RIG, or PIG? Clinical Radiology 58: , 2003.

5 29. August D, Teitelbaum D, Albina J, et al. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 26 (1Suppl):1SA-138SA, Lord LM. Restoring and maintaining patency of enteral feeding tubes. NCP 18 (5): , Berne JD, Norwood SH, McAuley CE, et al. Erthromycin reduces delayed gastric emptying in critically ill trauma patients: a randomized, controlled trial. J Trauma 53: , Mckibbin B, Cresci G, Hawkins M. Nutrition support for the patient with an open abdomen after major abdominal trauma. Nutrition 19: , Heyland DK, Schroter-Noppe D, Drover JW, et al. Nutrition suport in the critical care setting: current practice in Canadian ICUs-opportunities for improvement? JPEN 27 (1):74-83, Beale RJ, Bryg DJ, Bihari DJ. Immunonutrition in the critically ill: a systematic review of clinical outcome. Crit Care Med 27(12): , Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 29(12): , Review Questions 1. Common complications of nasoenteric tube placement and feeding may include: a. Aspiration b. Diarrhea c. Peritonitis d. Pneumothorax 2. An appropriate enteral feeding formula choice for a debilitated patient with advanced dementia and no known gastrointestinal or other organ pathology would be: a. Elemental formula b. Polymeric formula c. High fat specialty formula d. Concentrated renal formula 3. The strongest support for enteral in favor of parenteral nutrition comes from studies of: a. Patients with severe pancreatitis b. Patients with bowel obstruction c. Patients with mesenteric ischemia d. Patients with abdominal trauma 4. It is imperative that feedings be diluted upon initiation of tube feedings to promote tolerance. a. True b. False Answers: 1-a,b, 2-b, 3-d, 4-b