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ENTERAL NUTRITION. MEETING NUTRIENT NEEDS. 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

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enteral nutrition



selection of feeding route
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
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
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
Where can you get information about enteral products?
  • Nutrition Care Manual formulary page
  • http://nutritioncaremanual.org/universi13
  • Novartis Nutrition USAhttp://www.novartisnutrition.com/us/home
  • Abbot Nutrition Product Handbook http://abbottnutrition.com/productHandbook/default.aspNestle Nutrition http://www.nestleclinicalnutrition.com/
nutrition care manual formulary
Nutrition Care Manual Formulary

You 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
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 selection9
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 selection10
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 selection11
Enteral Formula Selection
  • Trauma/Critical Care: Traumacal, Perative, Impact, Alitraq, Oxepa, Promote, Pivot
  • Wound Healing: Isosource VHN, Replete, Promote, Juven (oral)
enteral selection12
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
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 selection14
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
Physical Properties of Enteral Formulas
  • Osmolality
    • GI emptying
    • Retention
    • Nausea
  • Residue
  • Viscosity
    • Size of tube is important
  • – Vomiting
  • – Diarrhea
  • – Dehydration
osmolarity vs osmolality
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)
  • 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
lower osmolality
Lower Osmolality
  • Large (intact) proteins
  • Large starch molecules
higher osmolality
Higher Osmolality
  • Hydrolyzed protein or amino acids
  • Disaccharides
  • Smaller particles
meeting nutrient needs
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
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
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 ree24
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-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
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 needs27
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
  • 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 (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
  • 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 needs
Fluid Needs

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
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 patients33
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 patients34
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
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 monitoring36
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
Enteral Feeding Tolerance
  • Signs and symptoms:


—Respiratory distress

—Nausea, vomiting, diarrhea

—Constipation, cramps


—Abdominal distention

monitoring gastric residuals
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
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 tract
Absorption/Secretion of Fluid in the GI Tract

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 residuals41
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 residuals42
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.