Enteral Nutrition

Dr. Noorulain

Fcps II trainee

Delivery of nutrients into the existing Gastrointetinal tract.

5-7 days of inadequate intake

Expected no intake for 7-9 days

prolonged anorexia

Inability to take oral feedings

Impaired intestinal function

Critical illnesses

Intestinal Obstruction

Intestinal Ischaemia/Perforation

Inability to access the gut.

Severe acute pancreatitis

High output proximal fistula

Shock

Preserves gut integrity

Possibly decreases bacterial translocation

Preserves immunological function of gut

Better tolerated by patient

Less costly than TPN

Oral dietary supplements

Polymeric feeds

Monomeric

Specialized diets

Disease-specific feeds

Gastric

Postpyloric

Advantages

More Physiological

Ease of placement

Formula osmolarity less problem

Disadvantages

Delayed gastric emptying

Gastroesophageal reflux and aspiration

Advantages

Minimize aspiration risk

Disadvantages

Difficulty with placement

Feeding intolerance

Nasogastric

Nasojejunal

Percutaneous endoscopic

gastrostomy

Open gastrostomy

Transgastric jejunostomy

Jejunostomy

If tube feeding is needed for ≤ 4 to 6 wk, nasogastric or nasoenteric is usually used.

Tube feeding for > 4 to 6 wk usually requires a gastrostomy or jejunostomytube.

Cheap

Easy to insert

Residual volume can be assesed

Disadvantages

Uncomfortable

Easily dislodged

Increase aspiration

risk

Decreased risk of aspiration

Decreased stimulus to pancreatic secretion

Indicated--gastric reflux

--delayed gastric emptying

Disadvantages

Not easy to place

Damage to gastric mucosa

Impaired absorbtion

Placement of tube through abdominal wall directly into stomach.

Now a days performed by percutaneousinsertion under endoscopic control known as PEG.

o Contraindications

o Gastric ulcer

o Gastric carcinoma

o Ascites

o Coagulation disorders

Complications

Sepsis around PEG site

Nectrotizing fascitis and intraabdominal wall abscess

persistent gastric fistula

creation of opening through skin at front of abdomen and jejunal wall.

Percutaneous Endoscopic jejunostomy

Technically difficult

Allows concomittent jejunal feeding and gastric decompression.

Bolus

Continuous

Intermittent

Cyclic

Bolus feeding

Large amount (300-400ml) is given in short time period several times daily

Continous feeding

Administration into the GIT via pump or gravity, usually over 8 to 24 hours per day

Intermittent feeding

300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe

Cyclic

via pump usually at night

Rate of administration

Gastric feeding

Standard formula : 50 cc/hr

Advanced by 25cc/hr every 4-8 hours until goal rate is made

Elemental formula :25cc/hr for first 12 hour

Advanced by 25cc/hr every 6-12 hour

Jejunal or duodenal feedings

Standard or elemental feeding at full strength at 25 cc/hr for first 12 hour then advanced by 25cc/hr every 6-12 hours.

Bolus feeding method not used.

Gastric feeds

Check residual volumes every 4 hours

Hold tube feeding residual greater than 200cc

Reinfuse residual recheck in 2 hours

Feeds should be held if increasing abdominal distention

Jejunal feeds

Monitor abdomen for distension

bowel sounds every 4 hours

Residual volumes are not helpful

Hold feeds if emesis abdominal pain or distension

Weight 3 times/wk Edema Daily dehydration Daily Fluid intakeDaily

output Nitrogen balance 2 times/wk Electrolytes BUN, Creatinine 2-3times/wk Glucose, Ca++, Mg++ weekly Stool output Daily

consistency

Tube related

Malposition

Displacemant

Blockage

Breakage/leakage

Local complication ( erosion of skin / mucosa )

Gastrointestinal

Diarrhea (most common an dperticularlycommon in critically ill

Bloating nausea vomiting

Abdominal cramps

Aspiration

Constipation

Metabolic

Refeeding syndrome

Electrolyte disorder

Vitamin mineral trace element deficiencies

Infective

Exogenous (handling contamination)

Endogenous (patient)

If the gut works Use it

Thank you…