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Implementing Enteral Nutrition: Formula Selection and Administration

Implementing Enteral Nutrition: Formula Selection and Administration. Objectives. To describe the categories of enteral formulas To explain how to choose the appropriate category of enteral formula for each patient’s disease state

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Implementing Enteral Nutrition: Formula Selection and Administration

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  1. Implementing Enteral Nutrition: Formula Selection and Administration

  2. Objectives • To describe the categories of enteral formulas • To explain how to choose the appropriate category of enteral formula for each patient’s disease state • To describe the various methods for delivering enteral nutrition and how to choose the most appropriate formula for each situation

  3. Enteral Formulas: Categories • Polymeric formulas – Commercial – Blenderized • Oligomeric formulas • Disease-specific formulas • Modular formulas (concentrated protein and carbohydrate preparations)

  4. Polymeric Formulas Contain intact macronutrients and require digestion: • Intact proteins • Polysaccharides • Disaccharides • Polyunsaturated fatty acids (PUFA) • Medium-chain triglycerides (MCT)

  5. Polymeric Formulas:Benefits of Commercial Formulas Gallagher-Allred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50 Sullivan MM, et al. J Hosp Infect 2001;49:268-273

  6. Commercial Polymeric Formulas: Selection Features • Protein, caloric density, and osmolality vary • With or without added fiber • Most are lactose- and gluten-free • Nutritionally complete in sufficient quantities Patient must have: • Functional GI tract • Normal digestion • Normal absorption

  7. Oligomeric Formula Categories Hydrolyzed macronutrients facilitate digestion and absorption Components • Amino acids – Glutamine – Arginine • Peptides • Monosaccharides • Disaccharides Also called “elemental,” “semi-elemental,” “hydrolyzed”, or “chemically defined” formula. • Glucose polymers • Polyunsaturated fatty acids • Medium-chain triglycerides • Vitamins and minerals In: Rombeau JL, Rolandelli RH, eds. Clinical Nutrition: Enteral and Tube Feeding. 3rd ed. WB Saunders Company; 1997

  8. Oligomeric Formulas: Selection Indications for Use: • Inflammatory bowel disease • Pancreatic insufficiency • Malabsorption • Short bowel syndrome • Radiation enteritis • Early enteral feeding • Intolerance to polymeric formula

  9. Enteral Formula Selection: Disease-Specific Formulas • Pulmonary disease • Glucose intolerance • Cancer-induced weight loss • Hepatic insufficiency • Critical care • Renal failure • HIV+/AIDS Cabre E, Gassull MA. Nutrition 1992;8:1-9.

  10. Disease-Specific Formula Selection:Pulmonary Disease (Chronic) Pulmonary disease with CO2 retention • Decreased carbohydrate content • Increased fat content • High caloric density • Intact proteins • Fiber supplement Brown RO et al. Clin Phar 1984;3:152-161; Askanazi J et al. Anesthesiology 1981;54:373-377Deitel M et al. J Am Coll Nut 1983;2:25-32

  11. Disease-Specific Formula Selection:Glucose Intolerance Glucose Intolerance • Diabetes mellitus – Type I – Type II • Hyperglycemia associated with: – Pancreatic disease – Drug and chemical-induced – Insulin receptor abnormalities – Hormonal alterations– Genetic syndromes– Metabolic stress Cabre E, Gassull MA. Nutrition 1992;8:1-9

  12. Disease-Specific Formula Selection:Glucose Intolerance Recommendations • Low carbohydrate content – Monosaccharides (fructose) – Glucose polymers • Increased monounsaturated fat (MUFA) • Added fiber Franz MJ, et al. Diabetes Care 1994;17:490-518; J Am Diet Assoc 1994;94:504-506 Diabetes Care 1997;20:514-517

  13. Disease-Specific Formula Selection:Cancer-Induced Weight Loss Cancer-Induced Weight Loss • Complex metabolic syndrome - anorexia, fatigue, early satiety • Significant weight loss & muscle wasting • Etiology is multifactorial – Pro-inflammatory cytokines – Acute phase response – Abnormal metabolism – Proteolysis inducing factor (PIF) • Cannot correct by additional calories alone Negative Prognosis & QOL

  14. Disease-Specific Formula Selection:Cancer-Induced Weight Loss Recommendations • High protein and Zn to build muscle • Low fat to avoid early satiety • Low in sucrose for better patient acceptance • High in fermentable fibers • Eicosapentaenoic acid (EPA) • Antioxidants (vitamins A, C, E and Se) • Folate and iron for anemia

  15. Disease-Specific Formula Selection:Hepatic Disease Hepatic Insufficiency • Altered protein metabolism and protein loss • Altered carbohydrate metabolism – glucose intolerance – low hepatic glycogen stores • Malabsorption of fat and fat-soluble vitamins • Inability to elongate or desaturate essential fatty acids • Vitamin and mineral deficiencies (e.g., B-complex and Zn) • Impaired urea synthesis with hyperammonemia and hepatic encephalopathy • Fluid and sodium retention • Reduced appetite/oral intake and taste impairment

  16. Disease-Specific Formula Selection:Hepatic Disease Recommendations • High caloric density with low sodium content • Moderately high calorie:nitrogen ratio • High in branched chain AAs and low in aromatic AAs • Non-digestible soluble fiber • Long-chain fatty acids and supplemental MCT • Supplemented with fat soluble vitamins, Zn, folic acid and B complex vitamins • Low copper, iron, manganese content

  17. Disease-Specific Formula Selection:Critical Care Types of Injury • Elective surgery • Minor trauma • Burn • Pressure ulcer • Patient Conditions • Sepsis • Inflammatory

  18. Disease-Specific Formula Selection:Critical Care • Nutrient Choices • Hydrolyzed or intact proteins • Glutamine • Arginine • Taurine, Carnitine • Eicosapentaenoic acid (EPA), Gamma-linolenic Acid (GLA) • Antioxidants Poullain et al. JPEN 1989;13:382-386; Lacey JM et al. Nutr Rev 1990;48:297-309 Barbul A et al. Surgery 1990;108:331-337

  19. Disease-Specific Formula Selection:Critical Care (Mechanical Ventilation) Lung Injury / SIRS / ARDS • Eicosapentaenoic acid (EPA) • Gamma-linolenic Acid (GLA) • Antioxidants • High caloric density • No arginine supplementation Gadek J. Chest 1998;114:277S; Gadek J. Crit Care Med 1999;27:1409-1420; Pacht ER, et al. Crit Care Med 2003;31:491-500

  20. Disease-Specific Formula Selection:Critical Care Arginine (a double-edged sword) • Conditionally essential nutrient that enhances wound healing • Supports immune system and is associated with reduced infectious complications “Giving arginine to a septic patient is like putting gasoline on an already burning fire.” - B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL

  21. Disease-Specific Formula Selection:Renal Disease Acute or Chronic Renal Disease • Increased BUN and creatinine • Increase in serum electrolytes: – Na – K – PO4– Mg Kopple JD. In: Shils ME et al eds. Modern Nutrition in Health and Disease. 8th ed. Philadelphia: Lea & Febiger; 1994:1102-1134; Blumenkranz MJ et al. Kidney Int 1982;21:849-851

  22. Disease-Specific Formula Selection:Renal Disease Recommendations • Protein content – Predialysis: 30 g/L – Dialysis: 70 g/L • Low electrolyte content • High caloric density Monson P, et al. J Renal Nutr 1994;4:58-77 ASPEN Board of Directors. JPEN 2002;26 Suppl 1

  23. Disease-Specific Formula Selection:Advanced AIDS (with weight loss) Advanced AIDS • Weight loss > 5% below normal • CD4 < 400 • Serum albumin < 3.0 g/dL • Opportunistic infection • Diarrhea • Impaired immune function Raiten DJ. Nutrition and HIV Infection. Department of Health and Human Services, Washington D.C. Grunfeld C et al. Sem Gastro Dis 1991; Kotler DP et al. Am J Clin Nutr 1985

  24. Disease-Specific Formula Selection:Advanced AIDS (with weight loss) Recommendations • Increased protein • Low fat for improved tolerance • Added fiber • EPA to down regulate metabolic changes associated with cachexia • Increased levels of antioxidants (beta-carotene, vitamin E, C) and B vitamins (B6, B12) Baum MK, et al. Ann N Y Acad Sci 1992;669:165-174Raiten DJ. Nutrition and HIV Infection. Dept. of Health and Human Services , Washington D.C.

  25. Enteral Formula: Selection • Metabolic requirements • Patient condition or status • Pre-existing conditions • GI function

  26. Enteral Formula: Selection • The physician should know the formula’s nutrient profile to meet specific patient needs • Understand the clinical evidence supporting specific formula use • Data obtained exclusively from animal models may or may not apply to the clinical setting

  27. Enteral Formula: Oral Administration Oral Supplementation • Indicated especially for patients with malnutrition or at risk for weight loss • When given between meals, does not reduce intake of other foods • Frequently stimulates increased intake of other foods • Thickened oral supplements are useful for patients with dysphagia

  28. Benefits of Oral Supplements Improvement in Oral Intake Proportional Increase Delmi M et al. Lancet 1990;335:1013-1016

  29. Enteral Formula: Tube Feeding Type: • Intermittent • Continuous: – 24 hours / day – During part of the day or at night Infusion Method: • Gravity • Infusion pump Gottschlich MN, Shronts EP, et al. Defined formula diets. In: Rombeau JL, Rolandelli, eds. Clinical Nutrition: Enteral and Tube Feeding. W B Saunders; 1997; Giocon JO et al. JPEN 1992;16:525-528

  30. Enteral Formula: Administration Enteral Feeding Intermittent • Resembles normal feeding and digestion patterns • 250-500 mL of formula • Administered over 30-60 minutes • 5-8 times daily

  31. Enteral Formula: Administration Continuous Plan 1 Beginning: Day 1: 1000 mL over 24 hours Progress: Day 2: 1500 mL over 24 hours Day 3: final volume according to needs Plan 2 Beginning: 25 mL/h (first 12 hours) Progress: 50 mL/h for next 12 hours rate according to needs

  32. Enteral Formula: Administration

  33. Enteral Formula: Administration Summary  • Intermittent feeding • Continuous feeding ASPEN Board of Directors. JPEN 2002;26 Suppl 1: 34SA.

  34. Summary • Described the categories of enteral formulas • Explained how to select appropriate formulas • Described the methods of enteral nutrition administration

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