Enteral Nutrition

HAIRUL IZLAN BIN MOHD SHAMSUDIN

 Gastrostomy

Placement of tube through abdominal

wall directly into stomach.
 Now a days performed by
percutaneous insertion under
endoscopic control known as PEG.
 GASTROSTOMY
Indication:
Long term requirement i.e. more than 8 weeks
Oesophageal ca , severe stoke , motor neuron disease ,
maxillo-facial injury

Percutaneous endoscopic gastrostomy

direct-stab technique push-through technique

 Complications
Sepsis around PEG site
Nectrotizing fascitis and
intraabdominal wall abscess
persistent gastric fistula
 Jejunostomy
creation of opening through
skin at front of abdomen and
jejunal wall.
 JEJUNOSTOMY
Indication:
Long term requirement of more than 8
weeks.
Surgery - Gastrectomy , surgery related to
oesophagus , pancreas , defects in gastric
emptying
Gastric Outlet obstruction
 Complications
Surgical jejunostomies :
Has a risk of leaking
Tube displacement

Both conditions could lead to peritonitis

Percutaneous Endoscopic jejunostomy
Technically difficult
Allows concomittant jejunal feeding
and gastric decompression.
Enteral Formula Categories

Polymeric formulas

Oligomeric formulas
 POLYMERIC FORMULAS
Composed of intact proteins, disaccharides and
polysaccharides and variable amount of fat.
Similar to average diet.
Calorie density 1kcal/ml
Nitrogen concentration of 5-7g/1000ml
Requires an intact gut for digestion.
Also includes disease specific formulas.
Lactose free and most are gluten free
Can be used orally also .
Examples are NUTREN optimum, ENSURE, GLUCERNA
etc
Subcategories Of Polymeric Formulas
CALORIC DENSE FORMULAS
2 kcal/ml or 1.5 cal/ml
Fluid restriction, Volume
intolerance, Electrolyte
abnormalities
Examples are Novasource
Renal, Suplena, Ensure plus
FIBER CONTANING FORMULAS
Fiber 5 -15g/L
For regulation of bowel
movement
Examples are Ensure,
Glucerna
 DISEASE SPECIFIC FORMULAS

RENAL FORMULA
Calorie dense, low electrolytes,
vary in proteins

Renal failure

Target to minimize BUN reduce

accumulation of toxic waste ,
maintain electrolyte & water
balance .

Examples are NOVASOURCE

RENAL, SUPLENA
 HEPATIC FORMULA
High in BCAA, low in AA, low in
electrolytes.
Hepatic failure, encephalopathy

Reduced in aromatic amino

acids & methionine , so as to
correct abnormal plasma ratio
of theses amino acid.

Example is SUPLENA
 DIABETIC FORMULA
Low in CHO
High fiber content.
Sucrose free
Example Glucerna, Glucerna SR,
Nutren Diabetic
IMMUNE ENHANCING
FORMULA
Metabolic stress, immune
dysfunction.
Arginine, glutamine, omega 3 FA,
anti oxidants
Examples are ENSURE PLUS,
IMPACT
OLIGOMERIC FORMULAS
Elemental formula

Partially hydrolyzed.

Hyperosmolar

Contains nitrogen in the form of free

amino acids or peptides.

Impaired digestive and absorptive capacity

Example is VITAL HN, PEPTAMEN

Formula Selection

Selection of appropriate
formula should be based on
the individual patients:

Medical and nutritional status

Digestive and absorptive
capabilities
Individual nutrient
requirements
ADMINISTRATION OF TUBE FEEDING

Methods of Feeding

Continuous infusion
Intermittent infusion
Bolus feeding
Guidelines for Initiating Enteral Feeding
Continuous Feeding
Begin undiluted feeding at a rate
between 10 and 50ml/hr.
Greater doubts about GI functions
should prompt lower infusion rates.
Increased the rate in increments of
20-40ml/hr, every 8-24hrs to attain
the required rate( calculated to
meet energy and protein
requirements), in as little as 1 day
or as many as 5 days, depending on
the state of GI tract.
The final rate should not exceed
125-150 ml/hr: high nutrient
requirement should met with 1.5-2
kcal/ml formulas.
 Discontinuation Of Feed

Discontinue enteral feeding only

when adequate oral intake has been
achieved.

When the likelihood of achieving oral

intake is uncertain, use weaning
methods such as
reducing the infusion rate,
interrupting the infusion before
meals
infusing only at night to improve
appetite and oral intake during the
day.
 Bolus Feeding
Begin with 50-100ml boluses of
undiluted feeding every 2-4 hrs.
Increase the size of boluses every 8-24
hrs, to 100ml, 150ml, 200ml. Etc. until
requirements are met.
In alert patients it is often possible to
begun with 250ml boluses and increase
the volume to as high as
400ml/feeding. If possible avoid
feeding during the night.
If water requirements are not met by
the formula, additional water should be
given with the flush.
Wean patients to oral intake by
eliminating feedings that precede
meals. Discontinue enteral feedings
only when adequate oral intake has
been achieved.
 Complications of Tube Feeding
GASTROINTESTINAL COMPLICATIONS
1. Diarrhea
Causes
Hypertonic feeding formulas
Hypoalbunemia
Bacterial contamination
Inadequate fiber in feeding
formulas
Certain infusion methods (e.g.
bolus infusions or rapid increases in
infusion rates)
Medications
Medications containing sorbitol
Magnesium containing antacids
Oral antibiotics (definite); IV
antibiotics, Phosphorous supplements,
histamine-2 receptor blockers,
metaclopramide, other assorted
medications.
Managing Diarrhea in Tube Feeding
Dos
Carefully review all medications
Eliminate all sorbitol containing
medications
Eliminate Mg containing antacids
Eliminate any other potential offenders
Consider giving psyllium (ispaghol) or pectin.
Don'ts
Dont stop the feeding any longer than is
necessary to determine whether it is causing
diarrhea.
Dont change the feeding formula with the
assumption that doing so will relieve the
diarrhea
 2.Constipation

Causes: Treatment
Inactivity Bowel stimulants
Decreased bowel Adequate hydration
motility
Decreased fluid Use of fiber-containing
intake formulas
Lack of dietary fiber Stool softeners
Poor bowel motility
and
Dehydration
 3.Nausea And Vomiting
Causes
Delayed gastric emptying
Abdominal distention
Treatment
Reducing narcotic
medications
Switching to a low-fat
formula
Administering the feeding
solution at room
temperature
Reducing the rate of
administration
Administering a
promotility
Check gastric residuals before
the next bolus feeding, or
every four hours for
continuous feeding.
If gastric residuals are low
yet nausea persists, consider
antiemetic medications.
MECHANICAL COMPLICATIONS
1) Aspiration
Risk factors for aspiration
include:
1) Decreased level of consciousness
2) Diminished gag reflex
3) Neurologic injury
4) GI reflux
5) Supine position
6) Use of large-bore feeding tubes
7) Large gastric residuals

Use of small-bore feeding tubes,

promotility agents, periodic
assessment of gastric residuals,
and keeping the head of the bed
elevated may reduce the risk of
aspiration
2)Tube malposition
3)Tube Clogging
 METABOLIC COMPLICATIONS

POSSIBLE ETIOLOGY POSSIBLE CAUSE POSSIBLE TREATMENT

Hyponatremia Excessive free water, Change to fluid

Abnormal sodium loss restricted formula,
Discontinue water
boluses, replace sodium
losses
Hypernatremia Inadequate hydration, Add or increase water
Increased fluid loses, boluses or IVF
Diabetic Insipidus
Hypokalemia Anabolism, refeeding, Supplement K
diuretics, medications

Hyperkalemia Renal failure, Correct imbalance

metabolic acidosis, Change to renal formula
catabolism, GI bleed, as appropriate
acute dehydration
POSSIBLE ETIOLOGY POSSIBLE CAUSE POSSIBLE TREATMENT
Hypophosphatemia Anabolism Supplement Phosphorus
Refeeding
Hyperphospatemia Renal failure Change to renal formula
Phosphate binders
Hypomagnesimia Anabolism, refeeding, Supplement Mg
diuretics, medications

Hyperglycemia Diabetes, Change to diabetic

Steroid therapy, formula
Sepsis, Trauma, Insulin drip per
Pancreatitis protocol
Goal is to maintain
blood glucose at or <
110 mg/dl
THANK YOU