Enteral NutritionDr Amit Kocheta DNB Trainee Anesthesiology & Critical Care Deptt. BMHRC

Enteral Nutrition is the administration of nutrients directly into the gastrointestinal tract. It is the preferred method for providing nutrition and should be used when the patient s GI tract is functional, before considering parenteral nutrition.

Definition Enteral Nutritionis the administration of nourishment via the GI tract. This includes liquid diets, soft and solid food diets, and special nutritionally complete formulas administered orally or via tubes.

Objectives Promotes the importance of nutritional support in order to improve the nutritional status of patients in hospital and the community.

Indications Poor nutrient retention Prolonged NPO status Insufficient intake Etiologies Underlying disease process Anorexia Prolonged NPO status Nutritional needs not assessed

Indications cont.. Gastrointestinal Disease Short bowel syndrome Inflammatory bowel disease Intractable diarrhea of infancy Extrahepatic biliary atresia Intestinal pseudo-obstruction Chronic liver disease Glycogen liver disease

Indications cont.. Preterm infants Neurologic Static encephalopathy Dysphagia CNS tumor

Cardiorespiratory Cystic fibrosis Bronchopulmonary dysplasia Congenital heart disease

Indications cont.. Malignancy Poor intake: radiation / chemotherapy Terminal support

Hypermetabolic states Burns Trauma / head injury

Other Anorexia nervosa Chronic renal disease

Physiologic and Metabolic BenefitsThe gut can be used Complex nutrients (Intact protein, peptide, fiber etc) Intact Nutrients Reduce risk of inflammation, ulceration and bleeding

Tropic Benefits on GI Mucosa Nourishing Enterocytes directly Nutrients of small bowel and colon Glutamine &SFA Normal Gut pH and flora Reduces bacterial overgrowth

Triggering of feeding dependent neuro-endocrine activity and preventing bacterial translocation Stimulation of manufacturing of SIG A

If tube feeding will be used for short term. Nasogastric Intubation refers to the insertion of a long, soft, polyethylene tube called the nasogastric tube (NGT) through the nasopharynx into the stomach. Nasoduodenal Intubation insertion of a tube into the nasal passages to the duodenum Nasojejunal Intubation insertion of a tube into the nasal passages to the jejunum

If feeding tube will be long term or permanent, it can be surgically made Esophagostomy insertion of a feeding tube into the esophagus using an endoscope. Gastrostomy / PEG (Percutaneous Endoscopic Gastrostomy) insertion of a feeding tube into the stomach which uses an endoscope and pulling the tube through a small incision in the abdominal wall. Jejunostomy / PEJ (Percutaneous Endoscopic Jejunostomy) feeding tube inserted into the jejunum using an endoscopic technique.

Esophagostomy

Gastrostomy/PEG

Jejunostomy / PEJ

G & J Tube : Insertion Site CareAfter 24 hours remove initial dressing and leave open to air Cleanse site daily with normal saline or mild soap and warm water Rotate the external bumper 90 degrees Assess the site for purulent drainage, increased redness or warmth, rashes and site tenderness

Maintenance Of Feeding Tube Position Measure and mark the tube Secure the tube with tape, dry dressings Occasionally sutured in place Vomiting, leakage or pain may be signs of device malposition

Methods Of Administration1. Continuous Infusion :- provides controlled delivery of a prescribed volume of formula at a constant rate over a continuous (usually 1624 hrs period) period using an infusion pump.

Methods Of Administration2. Intermittent Infusion :-delivering the quantity of formula needed for a 24-hr period in 3-6 equal feedings delivered by gravity during a 30-90 minute period

Methods Of Administration3. Bolus Feeding :- infusing volumes of formula by gravity or syringe over a short period of time (not to exceed 400 cc at a time)

Administering Enteral FeedingPlace patient in high Fowler s position or elevate head of bed 30 degrees Check tube placement [Xray if initiating] Advance tube feeding rate gradually Continuous feedings should be flushed with sterile water, & have residuals checked every 4-8 hrs and tube placement verified at that time

If formula is infusing continuously over 24 hours, the refillable delivery sets must be changed every 24 hours Formula is not to hang at room temperature for more than 6-8 hours Infusion pumps must be used for all J-tubes, and G-tubes when formula is infusing continuously over 24 hours

Checking Tube PlacementX-ray prior to initiating feeds & when unsure of position Listening for a whooshing or gurgling sound when air is inserted is no longer considered totally reliable by itself Measuring the pH (inject 30 mls of air into the tube and aspirate GI contents with a syringe and measure the pH) Gastric pH 1-4, intestinal pH >7,and Tracheobronchial pH>7

Gastric residuals check color

Enteral Device PatencyFlush tube with 30-50 cc of sterile water (only use water) every 4-6 hours, to maintain patency Flushing is also required before & after:infusion of any med via feeding tube; each interruption in feeding; and each period in intermittent feeding Use a pump for continuous feeds Prevent bacteria contamination in formula

Advantages Enteral 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

Preserves gut integrity Decreases likelihood of bacterial translocation Preserves immunologic function of gut Increased compliance with intake

Disadvantages Enteral Nutrition GI, metabolic, and mechanical complications tube 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)

GastroparesisNot complication but present in the patients who require enteral feeding Results from altered gut neurologic or muscular function (Neuropathy) and relese of mediators that inhibit gastric emptying Consistant high gastric residuals indicate Gastroparasis Use of promotility agents (Erythromycin, metaclopromide etc)

Gastroesopahgeal RefluxGastric pressure exceeds LES Pressure Gastric pressure increased by large gastric volumes and increased abdominal pressure due to fluid (Ascites) Especially evident when pt is in supine position with large-bore feeding tube Complications of reflux aspiration esophagitis, vomiting and

Keep low gastric volumes, head of the bed elevation and agents increase LES Pressure - Metaclopramide

Duodenal Gastric Reflux Large volume DG Reflux may indicate impared small bowel motility an increase gastric volume Reduced by promotility agents more distal placement of small bowel feeding tubes Usually minimal when feeding tube is beyond the ligament of Treitz

Diarrhea Common in Enterally fed pts (2% - 63%) Multiple small bowel movements does not indicate diarrhea Rarely results from Nutritional formula rather indicates malfunctioning of GI tract It is rarely necessary to stop Enteral Feeding

Possible Causes of Diarrhea in Tube - fed patientsNon Formula related diarrhea Medications (Antibiotics, H2 receptor antagonists, laxatives, Mg and phosphorus Mediators relaesed during inflammatory syndromes and sepsis Pancriatic insufficiency Delayed feedings causing bowel atropy or long term TPN only Increased bowel motility Pathogenic bacteria (Closteridium difficile, enterotoxins) Bacterial Overgrowth Cytomegalovirus Inflammatory Bowel Disease Impaction and Short Bowel Syndrome Formula Related Diarrhea Rapid infusion rate Rapid initiation and progression of feedings in small bowel High fat intake Lactose intolerance and Microbial contamination of Formula

ConstipationResult from inactivity, decreased bowel motility, decreased fluid intake, impaction or lack of dietary fibre Poor bowel motility can lead to impaction and abdominal distention Use of Antimotility agents (antocholinergics, opiods, calcium channel antagonists) Improved through hydration and fibre rich diets, stool softeners Abdominal roentgenogram may need to be done as diagnostic tool

Electrolyte and mineral deficiencies Concentrations in the blood should be monitored at frequent intervals

SodiumMajor controller of osmolality Clinical features (Hypo or Hypernatremia) relate to the nervous system (depressed mentation, confusion, irritability, coma, seizures, nausea, vomiting, anorexia and head ache) Excess of water intake leads to hyponatremia in hosp pts and excess secretion of Antidiuretic hormone. Treated with limitation in water intake Most common case of Hypernatremia Dehydration(Excess sweating, osmotic diuresis) Treated by administration of water

Hypo and Hypernatremia Hypo and Hypernatremia can be caused by low and high sodium intake Pts with increased lossed require treatment Sodium content of the IV Fluids may be checked when hypernatremia is evaluated

PottassiumPrimary intracellular cation of the body and major determinant of electrical membrane potential. Decreased Pottasium levels leads to cardiac arrhythmias, muscle weakness, impaired protein synthesis Loss of Pottassium Stools, GI Secretions and urine (especially with diuretics)

CalciumCorrect value of Calcium ={(normal albumin actual albumin) x 0.8} + actual calcium = corrected calcium value Long term depletion leads to osteoporesis Excess calcium administration during ischemic and septic states may be injurious to cell Supplementation should be only in amounts required to maintain normal concentrations Some authorities believe that calcium intake should be decreased or stopped during critical illnesses

PhosphorusImportant source of cell energy (e.g. ATP) Component of cyclic adenosine mono phosphate and cyclic guanosine mono phosphate Important for oxygen offloading from hemoglobin Synthesis of nucleotides Most of the circulating phosphorus in the ionised form Depletion causes sick - cell syndrome (all cells of the body demonstrate diminished function

Phosphorus Respiratory arrest with severe depletion Causes of hypo phosphatemia Administration of large amt of carbohydrates Drugs (insulin, epinephrine, phosphate binding antacids, sucralfate) Loss from GI tract and Kidneys Phosphorus level should be monitored frequently

Re-feeding Syndrome Acute intracellular shifts of electrolytes as cell anabolism is stimulated The electrolytes should be monitored and replaced as needed The blood glucose levels also should be monitored

Vitamin deficiencies Especially demonstrated in malnourished pts Fat soluble vitamins Require pancreatic enzymes and bile for absorption Conc. May be low in pancreatic insufficiency, cirrohsis and mal-absorption syndromes Vit K Synthesised by gut bacteria conc. Decreased in pts receiving antibiotics

Water soluble Vitamins Most common deficiencies are of folate, ascorbic acid and thiamine These vitamins need constant intake Thiamine is essential for metabolism of Carbohydrates

DehydrationCommon among pts receiving Enteral Nutrition Water needs average 1ml per calorie consumed Caused by concentrated formulas, high protein feeds (urea and diuresis), Increased BUN, sodium concentration, creatinine ratio suggest dehydration Treatment :- Restore intravascular volume and water balance

Possible Contraindications of Enteral FeedingTerminal illness Short Bowel Obstruction GI Bleeding Vomiting and Diarrhea Fistulas GI Ischemia Ileus GI Inflammation

Terminal Illness The potential complications may outweigh benefits Aspiration Diarrhea Over hydration Discomfort

Short BowelUsually require PN for 1 3 Months after surgery Some patients require long term TPN, electrolyte and fluid replacement Adaptation is accelerated by early institution of enteral feeding Specialised Gut rehabilitation program: Glutaminefeeding and recombinant human growth hormone to promote adaptation to EN

Obstruction Complete Mechanical Obstruction of GI Tract below duodenum Pseudo-obstruction (GI Motility Disorder) Cannot be resolved as contraindication to EN Partial obstruction can be circumvented Requires monitoring of GI Status Appropriate feeding site, formula, equipment, mode etc

GI Bleeding Chronic, slow upper GI Bleeding not contraindicated but anorexia, frequent nausea and vomiting (Small bowel feedings preferred than Gastric feedings) Feasibility of EN: Cause, amount, location and immediate GI Evaluation

Vomiting and diarrheaProtracted vomiting and Diarrhea is not absolute contraindication of Enteral Feeding Vomiting: Frequent episodes may tolerate small bowel feeding with gastric decompression or pro-kinetic agents Diarrhea: Assessed for type of diarrhea (Osmotic/Secretory/ Medications Antibiotics, magnesium and phosphorus) Mild to moderate diarrhea: Wait for symptomatic improvement (PN may be indicated, depending upon nutritional status and potential for depletion)

FistulasFeeding site away from fistula (Increase absorption and decrease losses) More Proximal or distal fistulas can be easily fed enterally Low to moderate fistula output easy management Jejunal fistulas, especially with high output, problematic combination of EN and PN, or PN for some days is recommended to ensure that nutrient, electrolyte and fluid needs are met, and problems are not worsened by feeding

GI IschemiaE.g. Critically ill patient with low Cardiac output, sepsis and MOF Rapid changes in mucosa is seen even with brief reduction in mesenteric blood flow (Reducing absorptive and barrier functions of gut) EN improve blood flow Maintain barrier effects

In Chronic occulsive and compression syndromes that limit blood flow to the mesentery drastically, potential risk of worsening Ischemia exists

Ileus Paralytic ileus quiet frequent in acutely ill patientsCommon surgical causes Perforation Intraperitonial hemorrhage Peritonitis and other intraabdominal infections Non-surgical causes Ischemia Hypokaelimia Head or spine injury Uremia Adverse drug effects Thyroid deficiency Severe uncontrolled diabetes

Ileus Ileus affects small bowel to a lesser degree Persistent gastric ileus can usually be circumvented with Post pyloric tube placement and gastric decompression

GI Inflammation Causes IBD Radiation /Chemotherapy

Bowel rest is recommended, recent studies support the use of EN

Assessment of GI Tolerance1. Abdominal Discomfort and pain 2. Nausea and vomiting 3. Abdominal distention 4. Bowel sounds 5. Stool pattern Fullness, cramping

Abdominal Discomfort Fullness, cramping and painMedications Delayed gastric emptying Motility disorders of small and large intestine Intestinal spasms or Ischemia Rapid infusion rate Fibre containing formula Tube displacement or migration

Nausea and vomiting Gastric irritation or atony Rapid infusion rate Distal obstruction Anxiety Activation of emetic centre by medication Other disease status

Abdominal distention Abdominal circumference Can be assessed by measuring ileac crest to ileac crest daily to monitor changes in abdominal distention

Enteral feedings may be stopped if it increases above 8 10 cm above baseline

Bowel sounds Presence Or absence is not a good indicator for Bowel function (Sound because of fluid and air)

Stool pattern Stool volume, Frequency, Consistency, Colour should be recorded. Normal bowel pattern should be compared with the current patterns

Aspiration Precautions Tube Feeding Residuals Head of bed elevation

Tube Feeding ResidualsGastric residuals are used to evaluate gastric emptying of Enteral FeedsHigh residue intolerance to gastric feedings and aspiration

Method of obtaining Gastric residualsAspiring through the feeding tube with syringe Residues should be reinstalled

Parameters for holding feedings>= 200ml with Nasogastric tube >=100 ml with Gastrostomy tubeAssociated symptoms of intolerance should be assessed

Tube Feeding ResidualsHigh residue from Gastrostomy tubes can lead to complications Feeding delayed on abdominal discomfort or distention Delay feedings for 1 hr and checking residue, if high residue persists with out associated clinical symptomsProkinetic agent (Erythromycin, metoclopramide) or Trans pyloric feeding tube (Gastric decompression if necessary)

Head - of - bed elevation >=30 Degree elevation is recommended for all tube fed patientthe potential Lessen consequences of Aspiration life-threatening

Large bore tubes may disrupt the function of lower esophageal sphincter increasing risk of aspiration

Aspiration DetectionClinical signs and symptomsDyspnea, tachypnea, wheezing, rales, tachycardia, cyanosis, anxiety and agitation Subsequent fever Aspiration pneumonia

Radiographic studiesNon specific and lack sensitivity

Use of colouring agentsReliability and validity is not tested Disadvantages Falsely elevated gastric pH, +ve hemoccult stool tests, formula contamination

Aspiration Detection Tracheal Glucose Measurements Unclear whether reliable Also found in diabetic patients

Hydration StatusHydration Assessment Physical Assessment Intake and Output Weight Changes

Physical Assessment Symptoms of overhydration Presence of edema, High urine output, Hypertension, Respiratory insufficiency, CHF

Dehydration Low urine output, dry mucous membranes, poor skin turgor, flat neck veins, lethargy, hypo tension, tachycardia and elevated BUN

Intake and outputEuvolemic patientsOral, IV or enteral Water excretion primarily through kidneys less through skin, lungs and stool

Fluid requirementInsensible fluid input = 300ml H2O due to oxidation Insensible fluid loss= 500ml through skin, 400 ml Lungs, 100 ml stool Hence Fluid loss Fluid input = 1000 300ml = 700ml

Fluid requirement Normal Daily insensible fluid loss = 700 ml Normal person Fluid Req. = Urine output + 700ml Fluid loss 500ml through moderate sweating (Abnormal) 1.0 1.5 Lt through severe sweating, high fever 0.5 3.0 Lt through exposed wound surface burns and body cavity

FluidFluid losses increases with Diarrhea, vomiting, high nasogastric drainage, excessive diaphoresis, polyurea, fever, open wounds, fistula losses and thermal injuries Losses should be replaced by adequate fluid and electrolytes Leaking of fluid in to the extravascular compartment in pts. With vasodilation or low serum oncotic pressue

Weight Changes Fluid Changes can be determined by daily Body weight changes 1 kg of wt change = 1L of fluid

Fluid Requirement Normal afibrile pts who are enterally fed 1 Lt of water per calorie fed or 30 35 ml per Kg per day

Fluid restriction may be indicated in Cardiac, Renal and liver dysfunction

Providing Extra FluidsOrally, IV, with medications, via flushes through an enteral feeding tube Extra Fluid RequirementAdd Fluid taken in orally, assess pts ability to ingest the amount consistently Total Fluid given via IV Water content of Tube feeding formula (80-85% ;800 850 ml/Lt of formula) Caloric Dense formula contains less water 60% Flushes and other medications Total Fluid given Total Fluid required (Can be given via oral, tube or IV

Providing Extra FluidsAssespatient body weight Edema BUN Serum Na+ Adequacy of intra vascular volume and Urine Output

Laboratory Data Less frequent in pts on EN But baseline metabolic and nutritional assessment parameters should be obtained

Enteral Tube Rupture To prevent tube rupture, use a pressure no greater than 40 psi Syringes smaller than 60mL for G tubes or Jtubes should not be used

Clogged TubesBest approach: Prevent clogs from occurring by flushing before and after meds, and q4-6h. If a clog occurs: attach 60 ml syringe to the end of the enteral device and attempt to aspirate for G-tube only If unsuccessful, fill the syringe with 5-10 mls of warm water and attach it to the end of the enteral device and instill over 1 minute Clamp tube for 5-15 minutes

If no success, may try: Pancreatic enzymes Mix with sodium bicarb

Mineral water Other Pharmacy preparations Pop Risk of bacterial contamination Contributes to future clogs

Remember: With adequate flushing, clogging should not be a problem

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

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 daily include 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 Units Tube Size Diameter of feeding tube is measured in French units 1F = 33 mm diameter Feeding tube sizes differ for formula types and administration techniques.

Enteral Nutrition Monitoring

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.

Thanks