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ENTERAL NUTRITION

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... Replete with Fiber, Nutren 1.5 Fiber, Fibersource, Fibersource ... increased fiber intake, concentrated or high-protein formulas. Enteral Nutrition Monitoring ... – PowerPoint PPT presentation

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Title: ENTERAL NUTRITION


1
ENTERAL NUTRITION
  • MEETING NUTRIENT NEEDS

2
Selection of Feeding Route
  • Page 536, Krause Figure 23-1
  • Algorithm or Decision Tree
  • Adequate oral intake
  • Oral intake supplements
  • Enteral nutrition support
  • Patients medical status
  • Anticipated duration of tube feeding
  • Risk for aspiration
  • Advantages and disadvantages of access route

3
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

4
Enteral Formulary
  • What products are available?
  • More cost effective to have formulary
  • Include multiple products, one main brand of each
    category

5
Where can you get information about enteral
products?
  • Nutrition Care Manual formulary page
  • http//nutritioncaremanual.org/universi13
  • Novartis Nutrition USAhttp//www.novartisnutritio
    n.com/us/home
  • Abbot Nutrition Product Handbook
    http//abbottnutrition.com/productHandbook/default
    .aspNestle Nutrition http//www.nestleclinicalnu
    trition.com/

6
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.

7
(No Transcript)
8
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,

9
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

10
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)

11
Enteral Formula Selection
  • Trauma/Critical Care Traumacal, Perative,
    Impact, Alitraq, Oxepa, Promote, Pivot
  • Wound Healing Isosource VHN, Replete, Promote,
    Juven (oral)

12
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

13
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

14
Enteral Selection
  • Substrates
  • CHO, protein, fat consider pts 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 aas for most
  • Tolerance factors
  • Osmolality, calorie and nutrient densities,
    residue content, etc.

15
Physical Properties of Enteral Formulas
  • Osmolality
  • GI emptying
  • Retention
  • Nausea
  • Residue
  • Viscosity
  • Size of tube is important

Vomiting Diarrhea Dehydration
16
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)

17
Osmolality
  • Isotonic formula osmolality 300 mOsm
  • Body attempts to restore the 280 300 mOsm
  • Enteral feedings range from lt 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

18
Lower Osmolality
  • Large (intact) proteins
  • Large starch molecules

19
Higher Osmolality
  • Hydrolyzed protein or amino acids
  • Disaccharides
  • Smaller particles

20
Osmolality of Selected Liquids/ Medications
21
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

22
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

23
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

24
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

25
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.
  • Its always best to estimate a range of needs,
    which reflects the imprecision of the tools
    available for our use.

26
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 (BMIgt30)
  • 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 10229-230.

27
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

28
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

29
Protein (continued)
  • Protein (N gm pro 6.25)
  • Based on Kcal intake (NPCN)
  • Normal 200-3001
  • Anabolism 1501
  • Protein malnutrition 1001
  • Critical illness 150-2001
  • Energy malnutrition gt2001

30
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!)

31
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
32
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 manufacts
    info
  • Subtract amt. free water from needs
  • Provide additional water via flushes

33
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

34
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

35
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)

36
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)

37
Enteral Feeding Tolerance
  • Signs and symptoms
  • Consciousness
  • Respiratory distress
  • Nausea, vomiting, diarrhea
  • Constipation, cramps
  • Aspiration
  • Abdominal distention

38
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

39
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

40
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 1875-85.
41
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 1875-85.
42
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 1875-85.
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