Introduction to Enteral Nutrition

Enteral Nutrition

Nutrition delivered via the gut Includes oral feedings and tube feedings

Enteral Tube Feeding

Nutritional support via tube placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)
Must have functioning GI tract

IF THE GUT WORKS, USE IT!

Exhaust all oral diet methods first.

Oral Supplements

Between meals Added to foods

Added into liquids for medication pass by nursing

Enhances otherwise poor intake May be needed by children or teens to support growth

Diagram of enteral tube placement.

Copyright 2000 by W. B. Saunders Company. All rights reserved.

Fig. 22-2. p. 468.

Conditions That Require Specialized Nutrition Support

Enteral Impaired ingestion

Inability to consume adequate nutrition orally

Impaired digestion, absorption, metabolism

Severe wasting or depressed growth

Parenteral Gastrointestinal incompetency Hypermetabolic state with poor enteral tolerance or accessibility

Algorithm for Decisions

Modified and adapted from Gorman RC, Morris JB: Minimally invasive access to the gastrointestinal tract. In Rombeau JL, Rolandelli RH, editors: Clinical nutrition: enteral and tube feeding, p 174, Philadelphia, 1997, WB Saunders; and Ali A et al: Nutritional support services, Nutritional Support Algorithms, 8(7):13, July 1998.

Indications for Enteral Nutrition

Malnourished patient expected to be unable to eat >5-7 days Normally nourished patient expected to be unable to eat >7-9 days Adaptive phase of short bowel syndrome Increased needs that cannot be met through oral intake (burns, trauma) Inadequate oral intake resulting in deterioration of nutritional status or delayed recovery from illness
ASPEN. The science and practice of nutrition support. A case-Based Core curriculum. 2001; 143

Contraindications for EN

Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted

ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143

Contraindications for EN

Inadequate resuscitation or hypotension; hemodynamic instability Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished

Advantages - Enteral vs PN

Preserves gut integrity Possibly decreases bacterial translocation

Preserves immunological function of gut

Reduces costs (EAL Grade II) Fewer infectious complications in critically ill patients (EAL Grade I) Safer and more cost effective in many settings

ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 147

ADA EAL, Critical Illness, accessed 8-07

AdvantagesEnteral Nutrition

Intake easily/accurately monitored Provides nutrition when oral is not possible or adequate Supplies readily available Reduces risks associated with disease state

DisadvantagesEnteral Nutrition

GI, metabolic, and mechanical complicationstube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax Costs more than oral diets (not necessarily) Less palatable/normal: patient/family resistance Labor-intensive assessment, administration, tube patency and site care, monitoring

Enteral Formulas

Liquid diets intended for oral use or for tube feeding Ready-to-use or powdered form Designed to meet variety of medical and nutrition needs Can be used alone or given with foods

Formula Selection
The suitability of a feeding formula should be evaluated based on Functional status of GI tract

Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)

Macronutrient ratios
Digestion and absorption capability of patient Specific metabolic needs Contribution of the feeding to fluid and electrolyte needs or restriction Cost effectiveness

Enteral Formulas

Determine best choice by medical and nutrition assessment Meet specific nutrition needs

Enteral Formulas

Complete formulas:
Enteral formulas designed to supply all needed nutrients when given in sufficient volume May also be used in smaller quantities to supplement regular diets

Enteral Formula Categories

Polymeric Monomeric

Fiber-containing
Disease-specific

Rehydration
Modular

Enteral Formula Categories Polymeric

Whole protein nitrogen source For use in patients with normal or near normal GI function
Protein isolate formulas
Protein that has been separated from a food (casein from milk, albumin from egg)

Blenderized formulas
May contain pureed meat, vegetables, fruits, milk, starches with v/m added Made at home or purchased commercially

Enteral Formula Categories Polymeric

Enteral Formula Categories Monomeric

Elemental/hydrolyzed Predigested nutrients

Free amino acids and/or short peptide chains

Has low fat content or high percentage of MCT, LCT, structured lipids

Enteral Formula Categories Monomeric

Enteral Formula Categories Monomeric

Use in patients with compromised digestive and/or absorptive capacity More expensive than standard formulas Tend to be more hyperosmolar because of small particle size

Enteral Formula Categories Fiber-Containing

Fiber-containing: containing a source of fiber; reportedly beneficial for prevention/treatment of altered bowel function in enterally fed patients Soy polysaccharide is the most common fiber additive in enteral feedings; effectiveness in treating diarrhea in tubefed patients unproven
ASPEN. The science and practice of nutrition support. A casebased core curriculum. 2001; 148

Enteral Formula Categories Fiber-Containing

Soluble fiber (guar gum, oat fiber, pectin) may exert trophic effect on colonic mucosa and be useful in normalizing bowel function

Most enteral feedings in amounts typically used contain less than recommended fiber intake for adults (20-35 g) Patients with impaired gastric emptying should not be fed fiber-containing formula into the stomach
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 148

Enteral Formula Categories Fiber-Containing

Enteral Formulas: Calorie Dense

May be used in fluid-restricted or volume-sensitive patients Useful for nocturnal feedings where nutrition must be delivered over brief time span

Calorie density ranges from 1.3 to 2 kcals/ml

Monitor fluid/hydration status

Enteral Formulas: Calorie Dense

Enteral Formula Categories Disease Specific

Designed for patients with specific disease states. Available for patients with respiratory disease, ARDS, diabetes, renal failure, hepatic failure, and immune compromise. Well-designed clinical trials may or may not be available (mostly not) Many of the trials have been done with formula cocktails, making it difficult to identify the operative variable

Enteral Formula Categories Disease Specific

Enteral Formula Categories Disease Specific

Pharmaceutical effects are claimed for many specialty enteral formulas (reduced LOS, reduced infections, reduced time on the ventilator) Mfrs are charging pharmaceutical prices (8-10 times more expensive than standard) Enteral formulas are classed as medical foods, not drugs and are regulated differently

Enteral Formula Categories Disease Specific

The FDA does not evaluate adult medical foods before they go on the market The government does not require that mfrs prove that formulas are safe and effective or that claims are valid FDA requires that formula mfrs use good manufacturing practices and that products are accurately labeled It is up to the clinician to evaluate the evidence that supports the claims regarding medical foods

Considerations in Evaluating Specialized Enteral Formulas

Is the nutrient profile appropriate based on the known metabolic needs and nutrient requirements of the condition Are there prospective double-blind RCTs to support claims (not case reports)

Data obtained using animal models may have limited application to humans
Product-specific research applies to that product only

Enteral Formulas Evaluating the Research

Research cannot always be generalized to a different population (studies in burn patients to trauma pts) Were the endpoints clinically significant (a biochemical marker only or important clinical outcome such as wound healing)? Who funded the study? Has the work been replicated?

Disease Specific Formulas Diabetic

Amount and type of CHO modified to reduce blood glucose response Increased fat content (may have increased monounsaturated fats) Results of studies using these formulas have been mixed Most standard enteral formulas fall within American Diabetes Association guidelines for macronutrient mix

Disease Specific Formulas Diabetic

Blood glucose control in acute care is often affected by illness, infection, other issues Patients on enteral feedings generally receive a more consistent CHO intake than persons on oral diets May be worth trying diabetes formulas in patients who have failed to achieve good blood glucose control on standard formulas

Disease Specific Formulas: Diabetic

Disease Specific Formulas Hepatic

Generally have reduced aromatic amino acids and increased branched chain amino acids More expensive than standard products Often lower in protein than standard formulas (may be too low for most liver patients) Research using these products has been inconclusive Standard (high protein) products are generally appropriate for patients with liver disease

Disease Specific Formulas Renal

Originally developed in an effort to delay the need for dialysis as long as possible Typically are calorie dense (2.0 kcal/cc) products with relatively low protein levels and modified electrolytes Generally too low in protein for dialyzed patients and acutely ill patients May be useful for short term use as supplement or calorie source in predialysis chronic renal failure patients

Disease-Specific Formulas Renal

Novasource Renal

Disease Specific Formulas Immune-Enhancing

Have added immune-enhancing nutrients (arginine, glutamine, omega-3 fatty acids, nucleotides) Results of research have been mixed Multiplicity of active ingredients makes it difficult to control variables Meta-analysis suggests that they might be most beneficial in surgical patients Some evidence of harm in septic patients

Immune-Enhancing EN in Critical Care: ADA Evidence-Based Guidelines

R.3 Immune-enhancing EN is not recommended for routine use in critically ill patients in the ICU. Immune-enhancing EN is not associated with reduced infectious complications, LOS, reduced cost of medical care, days on mechanical ventilation or mortality in moderately to less severely ill ICU patients. Their use may be associated with increased mortality in severely ill ICU patients, although adequately-powered trials evaluating this have not been conducted. Strength: Fair; imperative

Immune-Enhancing EN in Critical Care: ADA Evidence-Based Guidelines

For the trauma patient, it is not recommended to routinely use immuneenhancing EN, as its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation.

Source: ADA EAL Evidence-Based Guidelines, accessed 8/07

Immune-Enhancing Formulas

Disease-Specific Formula Pulmonary

Contain higher percentage of total calories from fat to reduce respiratory quotient and make it easier to wean from respirator However, total calorie intake has more impact on respiratory function than formula composition There is a lack of clinical trials demonstrating a clear benefit

High fat gastric feedings may cause delayed emptying in critically ill patients

Disease-Specific Formulas: Pulmonary

Enteral Formula Categories Rehydration and Modular

Rehydration: for patients requiring optimal ratio of carbohydrate to electrolytes to facilitate fluid and electrolyte absorption, rehydration Modular: provides protein, fat, or carbohydrate as single nutrients or modular mixtures to allow adjustment of macronutrient mix. May also contribute to renal solute load, osmolality

Enteral Formula Categories Modular

Enteral Formula Nutrient Sources Carbohydrate

CHO content ranges from 40-90% of total calories Typically some combination of hydrolyzed cornstarch, maltodextrins, corn syrup solids, sucrose FOS: fructooligosaccharides; poorly absorbed in the small intestine, fermented in the large intestine; may promote growth of healthy bacteria

Fiber: soy polysaccharide (most common) guar gum, oat fiber, pectin

Enteral Formula Nutrient Sources Lipids

Fat provides isotonic, concentrated energy source Corn and soybean oil common Also safflower, canola, fish oil May include MCTs; more easily digested and absorbed Fat content ranges from <10% to >50% of calories
ASPEN. The science and practice of nutrition support. A casebased core curriculum. 2001; 148

Enteral Formulas Nutrient Sources Protein

Whole protein, hydrolyzed protein, free amino acids Casein, soy protein, lactalbumin, whey, egg white albumin Small peptides absorbed as efficiently as free amino acids Free amino acids are more hyperosmolar

Enteral Formulas Nutrient Sources Protein

Arginine: conditionally essential amino acid with immune-enhancing properties. Research suggests some benefit in wound healing (rat studies and biochemical changes.) Recent research suggests may be harmful in septic patients

Glutamine: may enhance small intestine growth and repair; however, available research done with parenteral glutamine; enteral delivery not well studied

Enteral Formulas: Nutrient Sources Protein

Branched-Chain Amino Acids: evaluated in critical care and liver failure patients in the 70s and 80s

Thought to prevent or treat hepatic encephalopathy and prevent muscle catabolism

Studies using BCAA have been inconclusive Effectiveness of therapy cannot be evaluated based on current research BCAA sometimes recommended for refactory encephalopathy

Establishing an Enteral Formulary

Many health care organizations find it cost-effective to establish an enteral formulary based on clinical effectiveness and cost The health care organization or management company may purchase from one company or several

Establishing an Enteral Formulary

Evaluate common diagnoses of patients on enteral formulas and the formulas most often used in the past year

Identify categories of formulas that fill a need, such as standard 1 kcal/cc formula; standard 1 kcal/cc high protein formula; calorie dense formula (1.5 or 2.0 calories/cc); fiber-containing, monomeric, etc.
Write generic specifications for each product category

Establishing an Enteral Formulary

Identify commercially available products that fit into each category Where several formulas fit, choose based on cost, service, available packaging (closed vs open system)

Open vs Closed System

Open System

Product is decanted into a feeding bag Allows modulars such as protein and fiber to be added to feeding formulas Less waste in unstable patients (maybe) Shortens hang time Increases nursing time

Increased risk of contamination

Closed System or Ready to Hang

Containers sterile until spiked for hanging Can be used for continuous or bolus delivery No flexibility in formula additives

Less nursing time

Increases safe hang time Less risk of contamination More expensive than canned formula

Closed vs Open System

Open System

Closed System

Hang time 8 hours for decanted formula; 4 hours for formula mixtures Feeding bag and tubing should be rinsed each time formula replenished Contaminated feedings are associated with pt morbidity

Hang time 24-48 hours based on mfr recommendations Y port can be used to deliver additional fluid and modulars May result in less formula waste as open system formula should be discarded p 8 hours

Closed vs Open System

In a survey of nurses at MetroHealth, only 28% were aware of the 8 hour hang time for open system formulas written into nursing policy 55% recommended adding new formula to old, in violation of existing nursing protocol 66% could state the 24 hang time for closed system formulas

The cost of wasted formula is minimal compared to the cost of nursing time and risk of illness in patients

Luther H, Barco K, Chima CS, Yowler CJ. Comparative study of two systems of delivering supplemental protein with standardized tube feedings. J Burn Care Rehabil 2003;24:167-172.

Nursing Time Open vs Closed System (MetroHealth)

Figure 1. Total daily nursing time protein bolus vs open system
40 35 30 25 20 15 10 5 0 Open System Closed System/ Protein Flush 18.6 Minutes/day

36.6

N=5; P=.05

Luther H, Barco K, Chima CS, Yowler CJ. J Burn Care Rehabil 2003;24:167-172.