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