Enteral Nutrition Support

• Fluid and electrolyte requirements.

• Calculate enteral and parenteral nutrition formulations.

ENS

• Selecting the formula– Integrity of GI system– Type of protein, fat, CHO, fiber in

formula– Kcal & protein density of formula

ENS

• Selecting the formula– Ability of formula as taken to meet pt

nutrient needs– Viscosity of formula and TF equipment– Cost of formula

ENS Components

• Intact or polymeric formulas

• Hydrolyzed or elemental formulas

ENS Components

• Molality and molarity– number of free particles/unit wt or

volume– the higher the number the more free

particles– the higher the number more osmotic

force–mOsm

ENS Components

• Isotonic - – 350 mOsm/kg or less

• Intact formulas– 300 - 500 mOsm/kg

• Hydrolyzed nutrient formulas - hyperosmolar– 900 mOsm/kg

ENS Components

• Density of formulas–more nutrients or kcal/ml the more

dense– less free water

• Dense formulas used– restrict water– other source of water

ENS Components

• Protein– polymeric formulas - intact HBV protein

• What if small intestine can’t digest protein?

ENS Components

• CHO– starch hydrolysates–maltodextrins– sucrose– fructose– glucose

ENS Components

• CHO– osmolality increases as mover towards

simple sugars

ENS Components

• Fat– corn, soy, safflower, canola– need 4% of total kcal as linoleic– some have MCT

ENS Components

• Fluid– need to check free water– standard formulas - 80 - 85%– calorie dense - 60%

ENS Components

• Fiber– soy polysaccaharide– fructooligosaccharides– 10 - 12 g/L

• Chart showing narrowing the choice of formulas next

Narrowing the choice of formulas

ENS

• Things to consider when selecting– ability to digest– absorption– colonic residue– length of time on TF– risk of aspiration

ENS Routes of Admin

• Nasogastric

• Nasoduodenal or jasojejunal

• Enterostomies– percutaneous endoscopic gastrostomy

(PEG)– percutaneous endoscopic jejunostomy

(PEJ)

ENS Admin

• Bolus administration–maximum bolus - 400-450 ml– 4 - 6 times/day

• Check gastric residual

• Contraindications?

• Describe pt this might work?

ENS Admin

• Continuous drip– infusion 18 - 24 hours– start 30 - 50 ml/hr– advance 8 - 12 hr as tolerate– flush with water

• What steps would you take in planning a tube feeding?

Starting ENS

• 300 mOsm - full strength, full rate

• >600 mOsm - full strength, low rate & as tolerated advance

Monitoring ENS

• Table 22-5 Mahan

• What would you monitor?

Monitoring ENS

• Gastric residuals– >150-200 ml without feeding–maintain elevation– wait 30-60 min– check again

Monitoring ENS

• Gastric residuals– if always 150-200 ml– find out why– if have this and greater with feeding -

stop feeding or slow rate

Complications ENS

• Dehydration– why dehydrated– increase fluid– lower protein intake

Complications ENS

• Signs of excessive protein– dehydration– inadequate fluid intake– hypernatremia– hypercholremia

Complications ENS

• Signs of excessive protein– azotemia– pt appears confused

Complications ENS

• Aspiration pneumonia–make sure correct tube and placement

of end of tube– elevate head 30 degrees– continuous drip 22-24 hrs

Complications ENS

• Diarrhea– lactose intolerance– bacterial contamination– hyperosmolar formula– low serum alb–medication

END ENS

• Questions?

• Calculations next