Enteral Dan TPN

Enteral and
Parenteral
Nutrition Support
Raddi Moekdas
SMF Ilmu Kesehatan Anak
RSUD Tasikmalaya
2004, 2002 Elsevier Inc. All rights reserved.
Undernutrition in the hospitalised patients
Potter et al. BMJ 1998, 30 studies with 2062 randomised patients
Undernutrition is common (27-65%) in patients
admitted to hospital.
Hospitalisation frequently results in further
nutritional depletion.
Undernutrition is associated with inreased
morbidity and mortality.
What is Nutritional Support?
The provision of nutrients orally, enterally or
parenterally with therapeutic intent.
This includes, but is not limited to, provision of
total enteral or parenteral nutrition support,
and provision of therapeutic nutrients to
maintain and /or restore optimal nutrition
status and health.
ASPEN, 2002
Enteral (GI Tract) versus Parenteral
(IV) Nutrition
Not a flip of the coin decision
If the gut works, use it!
Enteral Nutrition Definition

Nutritional support via placement through
the nose, esophagus, stomach, or intestines
(duodenum or jejunum)
Tube feedings
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
Conditions That Require Other
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

Conditions That Often Require Nutritional
Support
Support contd
Support contd
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.
Considerations in Enteral Nutrition
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance
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 Formula Categories
Factors to Consider When Choosing an Enteral
Formula
Enteral Access: Clinical Considerations
Duration of tube feeding
Nasogastric or nasoenteric tube for short term
Gastrostomy and jejunostomy tubes for
long term
Placement of tube
Gastric
Small bowel
Placement Site
Access (medical status)
Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning
Enteral Tube Placement
AdvantagesEnteral Nutrition
Intake easily/accurately monitored
Provides nutrition when oral is not
possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with
disease state
More Advantages
Enteral Nutrition
Preserves gut integrity
Decreases likelihood of bacterial
translocation
Preserves immunologic function of gut
Increased compliance with intake

DisadvantagesEnteral Nutrition
GI, metabolic, and mechanical
complicationstube migration; increased
risk of bacterial contamination; tube
obstruction; pneumothorax
Costs more than oral diets
Less palatable/normal
Labor-intensive assessment, administration,
tube patency and site care, monitoring
Complications of Enteral Feeding
Access problems (tube obstruction)
Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)
Aspiration Pneumonia
Can result from enteral feeds
High-risk patients
Poor gag reflex
Depressed mental status
Reducing Risk of Aspiration
Check gastric residuals if receiving gastric
feeds
Elevate head of the bed >30 degrees during
feedings
Postpyloric feeding
Nasoenteric tube placement may require
fluoroscopic visualization or endoscopic
guidance
Transgastric jejunostomy tube
Rate and Method of Delivery*
Bolus300 to 400 ml rapid delivery via syringe
several times daily
Intermittent300 to 400 ml, 20 to 30 minutes,
several times/day via gravity drip or syringe
Cyclicvia pump usually at night
Continuousvia gravity drip or infusion pump

*Determined by medical status, feeding route and
volume, and nutritional goals
Consideration of Physical Properties
of Enteral Formulas
Residue
Viscosity
Size of tube is important
Osmolality: consider protein source
Intact (do not affect osmolality)soy
isolates; sodium or calcium casein;
lactalbumin
Hydrolyzed (more particles)peptides or
free amino acids

Renal Solute Load
Normal adult tolerance is 1200 to 1400
mOsm/L
Infants and renal patients may
tolerate less

Lower Osmolality
Large (intact) proteins
Large starch molecules
Higher Osmolality
Hydrolyzed protein or amino acids
Disaccharides
Tolerance
Signs and symptoms:
Consciousness
Respiratory distress
Nausea, vomiting, diarrhea
Constipation, cramps
Aspiration
Abdominal distention
Tolerancecontd
Other signs and symptoms
Hydration
Labs
Weight change
Esophageal reflux
Lactose/gluten intolerances
Glucose fluctuations

How to Determine Energy and
Protein
kcal/ml x ml given = kcal
% protein x kcal = kcal as protein
kcal as protein x 1 g/4 kcal = g protein
Example: Patient drinks 200 cc of a 15.3%
protein product that has 1 kcal/ml
1 kcal/ml x 200 ml = 200 kcal
0.153 % protein x 200 kcal = 30.6 kcal
30.6 kcal x 1g protein/4 kcal = 7.65 g protein
Energy in Formulas
1 to 1.2 kcal/ml = usual concentration
2 kcal/ml = highest concentration
Protein
From 4% to 26% of kcal is possible
14% to 16% of kcal is usual
18% to 26% of kcalconsidered to be
high-protein solution
Recommended Water
Healthy adult: 1 ml/kcal or 35 ml/kg
Healthy infant: 1.5 ml/kcal or 150 ml/kg
Normal tube feeding: 1 kcal/ml; 80% to
85% water
Elderly: consider 25 ml/kg with renal, liver,
or cardiac failure; or consider 35 ml/kg if
history of dehydration

Sources of Fluid (Free Water)
Liquids
Water in food
Water from metabolism
With tube feeding, nurse will flush tube with
water about 3 times dailyinclude this
amount in estimated needs
Example: flush with 200 cc tid

Administration: Feeding Rate
Continuous method = slow rate of 50 to 150
ml/hr for 12 to 24 hours
Intermittent method = 250 to 400 ml of
feeding given in 5 to 8 feedings per 24 hours
Bolus method = may give 300 to 400 ml
several time a day (push is not desired)
French UnitsTube Size
Diameter of feeding tube is measured in
French units
1F = 33 mm diameter
Feeding tube sizes differ for formula types
and administration techniques.
Examples of Special Formulas
Pediatrics
Low residue
High protein
Volume restriction
Diabetic
Pulmonary/COPD
Enteral Nutrition Monitoring
Routes of Parenteral Nutrition
Central access
TPN both long- and short-term placement
Peripheral or PPN
New catheters allow longer support via
this method limited to 800 to 900 mOsm/kg
due to thrombophlebitis
<2000 kcal required or <10 days
PPN vs. TPN
Kcal required
(10% dextrose max. PPN conc.)
Fluid tolerance
Osmolarity
Duration
Central line contraindicated
Venous Sites from Which the Superior Vena Cava
May Be Accessed
AdvantagesParenteral Nutrition
Provides nutrients when less than
2 to 3 feet of small intestine remains
Allows nutrition support when GI
intolerance prevents oral or enteral
support
Indications for Total
Parenteral Nutrition
GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food
Contraindications
GI tract works
Terminally ill
Only needed briefly (<14 days)
Calculating Nutrient Needs
Avoid excess kcal (> 40 kcal/kg)
Adults
kcal/kg BW
Obeseuse desired BMI range or an
adjusted factor
Adjusted Body Weight
Adjusted IBW for obesity
Female:
([actual weight IBW] x 0.32) + IBW
Male:
([actual weight IBW] x 0.38) + IBW
Parenteral Components
Carbohydrate
glucose or dextrose monohydrate
3.4 kcal/g
Amino acids
3, 3.5, 5, 7, 8.5, 10% solutions
Fat
10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml
Protein Requirements
1.2 to 1.5 g protein/kg IBW
mild or moderate stress
2.5 g protein/kg IBW
burns or severe trauma
Carbohydrate Requirements
Max. 0.36 g/kg BW/hr
Excess glucose causes:
Increased minute ventilation
Increased CO2 production
Increased O2 consumption
Lipogenesis and liver problems
Lipid Requirements
4% to 10% kcals given as lipid meets
EFA requirements; or 2% to 4% kcals
given as lineoleic acid
Usual range 25% to 35% max. 60% of
kcal or 2.5 g fat/kg
Other Requirements
Fluid30 to 50 ml/kg
Electrolytes
Use acetate or chloride forms
to manage acidosis or alkalosis
Vitamins
Trace elements
Calculating the Osmolarity of a
Parenteral Nutrition Solution
1. Multiply the grams of dextrose per liter by 5.
Example: 50 g of dextrose x 5 = 250 mOsm/L
2. Multiply the grams of protein per liter by 10.
Example: 30 g of protein x 10 = 300 mOsm/L
3. Fat is isotonic and does not contribute to
osmolarity.
4. Electrolytes further add to osmolarity.
Total osmolarity = 250 + 300 = 500 mOsm/L

Compounding Methods
Total nutrient admixture of amino acids,
glucose, additives
3-in-1 solution of lipid, amino acids,
glucose, additives
Administration
Start slowly
(1 L 1st day; 2 L 2nd day)
Stop slowly
(reduce rate by half every 1 to 2 hrs
or switch to dextrose IV)
Cyclic give 12 to 18 hours per day
Monitoring and Complications
Infection
Hemodynamic stability
Catheter care
Refeeding syndrome
Refeeding Syndrome
Hypophosphatemia
Hyperglycemia
Fluid retention
Cardiac arrest
Monitor
Weight
(daily)
Blood
Daily
Electrolytes (Na
+
, K
+
, Cl
-
)
Glucose
Acid-base status
3 times/week
BUN
Ca
+,
P
Plasma transaminases
Monitorcontd
Blood
Twice/week
Ammonia
Mg
Plasma transaminases
Weekly
Hgb
Prothrombin time
Zn
Cu
Triglycerides
Monitorcontd
Urine:
Glucose and ketones (4-6/day)
Specific gravity or osmolarity (2-4/day)
Urinary urea nitrogen (weekly)
Other:
Volume infusate (daily)
Oral intake (daily) if applicable
Urinary output (daily)
Activity, temperature, respiration (daily)
WBC and differential (as needed)
Cultures (as needed)
Problems
PPN
Site irritation
TPN
1. Catheter sepsis
2. Placement problems
3. Metabolic

Pediatric
Energy
Infant
50 to 60 kcal/kg/day maintenance
70 to 120 kcal/kg/day growth
Child >1yr
BEE
1to 8 yrs 70 to 100 kcal/kg/day
8 to 12 yrs 60 to 75 kcal/kg/day
12 to 18 yrs 45 to 60 kcal/kg/day
Injury factors
1.25 mild stress
1.50 nutritional depletion
2.00 high stress
Pediatriccontd
Protein:
Infant
2.4 to 4 g/kg/day <1500 g weight
2.0 to 2.5 g/kg/day 0 to 12 months
normal weight
Child >1 year
1 to 8 years 1.5 to 2.0 g/kg/day
8 to 15 years 1.0 to 1.5 g/kg/day
Pediatriccontd
Carbohydrate
Infant preterm:
4 to 6 mg/kg/minute begin rate
Term infants:
8 to 9 mg/kg/minute begin rate
Fat
Infants:
0.5 to 1.0 g/kg/day min for EFA needs
2 to 3 g/kg/day max
Vitamins and minerals:
See tables in textbook
Pediatriccontd
Fluid and electrolytes
Infant:
LBW 125 to 150 ml/kg/day
2 to 4 mmol/kg/day for electrolytes

Other infants and children

Document in Chart
Type of feeding formula and tube
Method (bolus, drip, pump)
Rate and water flush
Intake energy and protein
Tolerance, complications, and
corrective actions
Patient education

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