Enteral Nutrition: The Right Formula, The Right Time and the Right Way

1
Enteral Nutrition The Right Formula, The Right
Time and the Right Way

• Daria C. Ruffolo RN MSN-CS CCRN TNS ACNP
• Trauma/Surgical Critical Care NP
• Loyola University Medical Center
• druffol_at_lumc.edu

2
Hyperalimentation

• Implemented in the 1960s a move from pure
  glucose to administration of protein, lipids,
  vitamins and minerals to critically ill and
  injured patients
• Prevention of muscle-wasting and starvation

3
Too much of a good thing

• TPN came into question in the 1970s with the
  first earmarked complication of line infections
• It was at this time clinicians began seeking
  avenues for feeding their patients utilizing the
  GI tract

4
A Look Back

• Feeding enterally dates back to the 18th c
• 19th c rectal feeding was common place with a
  move toward gastric feeds
• 1910 was the inception of the first small bowel
  feeding, a rubber tube that was 16-20 fr. with a
  10 gm weight was instilled through the mouth into
  the small bowel using a slip of steel to provide
  firmness
• 1970 was the invention of the first small-bore
  weighted silastic or poluyurethene tube

5
Why Does the Gut Make us Happy?

• If there is an intact and at least partially
  function GI tract EN should be considered
• Early EN (72 hrs) has been demonstrated to
• --improve nitrogen balance
• --decrease the hypermetabolic response to tissue
  injury (DO2/VO2)

6

• --improve wound healing
• --increase host immune function
• --augment cellular anti-oxidant systems
• --preservation of the intestinal mucosal
  integrity
• Including (The Gut is the Motor of Sepsis)
• Maintaining mucosal immunity
• Prevention of increased mucosal permeability
• Decrease bacterial translocation
• Marik,
  Zaloga CCM 2005

7
Is Bacterial Translocation a True Threat?

• First investigated in the 1960s
• Not until 1980s was there more light on the
  topic particularly in the Burn literature
  (Gamelli, 1992 JOT)
• It is clear that the intestinal mucosa functions
  as a physiologic local defense to prevent
  bacteria and endotoxins from escaping and
  reaching extraintestinal tissues and organs

8

• Theory of BT
• --SB and colon contain 1010 anaerobes and 107
  each of Gram pos and Gram neg aerobes and enough
  endotoxin to kill us 1000X
• --Under certain circumstances this remarkable
  barrier can become overwhelmed or impaired and
  allowing its contents to move into mesenteric
  lymph tissue and subsequent systemic tissues
• 
  Magnotti Deitch 2005 JOABA

9
What Can We Do To Offset this?

• Resuscitate the patient
• Serial survey for infection
• FEED EARLY FEED ENTERALLY!
• (even minimally)
• --supports intestinal architecture by maintaining
  mucosal mass, stimulating cell proliferation,
  maintaining villus height

10

• Supports functional integrity by
• --maintaining tight gap junctions, stimulation of
  blood flow to the gut, and the production of
  endogenous agents such as cholecystokinin,
  gastrin and bile salts that exert a stay alert
  stay alive message to the gut

11
What is Early Feeding?

• In the 1970s it was a basic understanding that
  after trauma, surgery or critical illness there
  was an obligatory pan-ileus effect.
• ASPEN 2003/ACCP 2001
• Begin in 48-72 hours
• --After shock states
• --After effective resuscitation

12
Gastric vs. Small Bowel

• Is there an advantage?
• The stomach is particularly sensitive
• to severe illness and injury a resulting
  GASTROPARESIS can occur in gt 60 of ICU patients
  putting them at risk for the high gastric
  residuals -- gastroesophageal reflux
• --aspiration syndrome Zaloga CCM 2002

13
Thus the Move to the Deep Feeding Tube

• Accessing the post-pyloric domain is easier said
  then done!
• What are the advantages of a deep tube
• --aspiration is a real threat
• 1. 45 normal people aspirate in sleep
• 2. 70 with altered LOC
• 3. gt 70 of trauma patients at injury
• 4. gt 40 of patients with EN
• 
  Bowman, et al CCNQ 2005

14
Risk Factors for Reflux/Aspiration

• Decreased LOC
• Intubation ANY kind
• Supine positioning
• Surgery
• Anesthesia
• Obesity

15

• Goals with Deep Tube are to
• Minimized reflux/aspiration
• Improvement in visceral proteins
• (Prealbumin, transferrin, UUN, ?Met carts)
• Improvement in total caloric intake with
  minimized residuals and interruptions (ICU
  patients get 65 TOTAL calories)
• 
  Stone et al AACN Clin Iss 2000

16
(No Transcript)
17
CORTRAK Monitor

• Displays track of the feeding tube during
  placement

18
Key Benefits

• Safer
• 100 success rate in avoiding lung placement in
  clinical trial
• More Accurate
• Guides the clinician through the placement
  process by indicating the path of the tube as it
  is placed
• Less Expensive
• Fewer X-rays
• Reduced use of TPN
• No Fluoro
• Faster
• During clinical trials, placements averaged 10.5
  minutes

19
How Do We Minimize Aspiration vs. Gastric Reflux

• Gastric residuals (GR) are a reality
• The stomach produces 3 L/d
• Too much volume in the gastric reservoir will
  result in overflow into the esophagus
• Data suggests that gastric residual gt 200 cc
  should have feedings held for 2 hours and re-eval

20

• There has not good data to support high residual
  resulting in direct aspiration and subsequent
  pneumonia-- HOWEVER, there is a higher incidence
  of regurgitation, vomiting and lack of
  nutritional benefit
• 
  Lukan, AJCC 2002

21
What Do You Do With The Aspirate?

• There has been no higher incidence of
  complications in the discard vs. the refed.
• Weigh the oddsuse good discretion.
• 
  Booker, et al, AJCC 2000

22
Safer and Effective Administration

• Verify placement DOCUMENT!!
• NO FOOD COLOR
• Glucose testing of secretions
• Feed DEEP!
• Gastric motility agents
• Bowel programs
• Good glucose control

23
Elevate the HOB!

• Drakulovic 1999-- looked at gastroesophageal
  reflux in the supine vs. semi-fowler position

24
When Not to Push the Gut

• SBO/LBO
• Severe or complicated pancreatitis (sometimes fed
  distally or efferently)
• High output fistulae
• SEVERE diarrhea resulting in dehydration or
  electrolyte imbalance (rare)
• Severe colitis
• Hemodynamic instability with massive vasopressor
  support (remember fight or flight)
• Ischemic bowel
• Severe GI bleed

25
What About Immune Enhancing Diets (IED)?

• There are many up and coming but the targeted
  compounds have included arginine, omega-3 fatty
  acids, and glutamine
• They are costly
• Regular Formula 45/day
• Enriched Formula 220/day
• 
  Heyland, ASPEN, 2003

26
Who Needs An IED?

• ASPEN ICU Guideline
• --flail chest/pulmonary contusion
• --major abdominal trauma
• --two or more of the following
• a) gt 6 units blood
• b) major pelvis fracture
• c) 2 or more long bone fractures

27

• --non-trauma patients at risk for major septic
  morbidity
• --large abdominal operative cases
• --previously malnourished surgical patients

28
Do They Help?

• ASPEN Guidelines for Mechanically Ventilated and
  Critically Ill Adult Patients 2003
• ARGININE
• A semi-essential amino acid that promotes
  collagen synthesis and promotes wound healing.
  It also increases the total number of lymphocytes
  and contributes to nitrogen balance.

29

• Though there are some low powered studies looking
  at improved wound healing the meta-analysis of
  the more powerful studies has never looked at
  arginine alone.
• 2 Level 1 Studies
• 12 Level 2 Studies
• Recommendation No Improvement in outcome or
  impact on morbidity or mortality

30
Fish Oils

• Omega 3 FA alter the FA composition of the
  membrane phospholipid layer and move towards a
  reduction in the inflammatory cascade.

31

• FISH OILS
• 1 Level 1 study that included fish oils, borage
  oils and anti-oxidants TOGETHER (Oxepa) had an
  improved outcome in ARDS patients with decreased
  oxygen requirements and decreased ventilator
  days.

32
Glutamine

• Helps maintain GI mass, function, and integrity
• Assists in supporting the immune system by
  fueling the lymphocytic and macrophage production
  and activity

33

• 4 level 2 studies
• 2 level 1 studies
• That support the use of glutamine in the trauma,
  burn population and in the surgical critical care
  population

34
What About the Clogged Tube!

• PREVENTION!
• --even with continuous feeds flush the tube q
  4-6 hours FLUSH FLUSH
• --flush with warm water 30cc using a 30 cc
  syringe or larger
• --give each med separately
• --get orders for elixirs
• --yeast transfer narrows lumen use gloves!

35
Declogging

• Gentle flush and back pressure with 30cc or
  larger syringe
• Allow warm water to dwell
• Utilize ONLY sanctioned enzymatic decloggers---NO
  DIET COKE!
• Patience works wonders

36
Does Your Patient Have A Green Pocketbook

• Diarrhea is seen in 20-60 of EN patients
• Usually secretory, eval the osmolality of the
  formula (only isotonic feeds deep)
• R/O C. Difficile
• Be certain there is no impaction
• No need to stop feeds
• Keep up with free H2O
• May benefit from fiber agents, opioids
• 80 resolve in a few days