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Enteral and

ParenteralNutrition Support

Raddi MoekdasSMF Ilmu Kesehatan Anak

RSUD Tasikmalaya


2/68 2004, 2002 Elsevier Inc. All rights reserved.

Undernutrition in the hospitalised patientsPotter et al. BMJ 1998, 30 studies with 2062 randomised patients

Undernutrition is common (27-65%) in patientsadmitted to hospital.

Hospitalisation frequently results in furthernutritional depletion.

Undernutrition is associated with inreasedmorbidity and mortality.



What is Nutritional Support?

The provision of nutrients orally, enterally orparenterally with therapeutic intent.

This includes, but is not limited to, provision oftotal enteral or parenteral nutrition support,

and provision of therapeutic nutrients to

maintain and /or restore optimal nutritionstatus and health.

ASPEN, 2002



Enteral (GI Tract) versus Parenteral(IV) Nutrition

Not a flip of the coin decision

If the gut works, use it!



Enteral Nutrition Definition

Nutritional support via placement throughthe nose, esophagus, stomach, or intestines(duodenum or jejunum)

Tube feedings

Must have functioning GI tract

IF THE GUT WORKS, USE IT!

Exhaust all oral diet methods first.



Oral Supplements

Between meals

Added to foods

Added into liquids for medication passby nursing

Enhances otherwise poor intake

May be needed by children or teens tosupport growth



Conditions That Require OtherNutrition Support

Enteral

Impaired ingestion

Inability to consume adequate nutrition

orallyImpaired digestion, absorption, metabolism

Severe wasting or depressed growth

ParenteralGastrointestinal incompetency

Hypermetabolic state with poor enteraltolerance or accessibility



Conditions That Often Require NutritionalSupport



Conditions That Often Require NutritionalSupportcontd



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.



Considerations in Enteral Nutrition

1. Applicable

2. Site placement

3. Formula selection

4. Nutritional/medical requirements

5. Rate and method of delivery

6. Tolerance



Formula Selection

The suitability of a feeding formula should beevaluated based on

Functional status of GI tract

Physical characteristics of formula (osmolality,

fiber content, caloric density, viscosity)

Macronutrient ratios

Digestion and absorption capability of patient

Specific metabolic needs

Contribution of the feeding to fluid and electrolyteneeds or restriction

Cost effectiveness



Enteral Formula Categories



Factors to Consider When Choosing an EnteralFormula


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2004, 2002 Elsevier Inc. All rights reserved.

EnteralAccess: Clinical Considerations

Duration of tube feeding

Nasogastric or nasoenteric tube for short term

Gastrostomy and jejunostomy tubes forlong term

Placement of tube

Gastric

Small bowel


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Placement Site

Access (medical status)

Location (radiographic confirmation)

Duration

Tube measurements and durability

Adequacy of GI functioning


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Enteral Tube Placement


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AdvantagesEnteral 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 withdisease state


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More AdvantagesEnteral Nutrition

Preserves gut integrity

Decreases likelihood of bacterial

translocation Preserves immunologic function of gut

Increased compliance with intake


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DisadvantagesEnteral Nutrition

GI, metabolic, and mechanicalcomplicationstube migration; increasedrisk of bacterial contamination; tube

obstruction; pneumothorax Costs more than oral diets

Less palatable/normal

Labor-intensive assessment, administration,tube patency and site care, monitoring


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Complications of Enteral Feeding

Access problems (tube obstruction)

Administration problems (aspiration)

Gastrointestinal complications (diarrhea)

Metabolic complications (overhydration)


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Aspiration Pneumonia

Can result from enteral feeds

High-risk patients

Poor gag reflex

Depressed mental status


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Reducing Risk of Aspiration

Check gastric residuals if receiving gastricfeeds

Elevate head of the bed >30 degrees during

feedings

Postpyloric feeding

Nasoenteric tube placement may requirefluoroscopic visualization or endoscopicguidance

Transgastric jejunostomy tube


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Rate and Method of Delivery*

Bolus300 to 400 ml rapid delivery via syringeseveral times daily

Intermittent300 to 400 ml, 20 to 30 minutes,

several times/day via gravity drip or syringe

Cyclicvia pump usually at night

Continuousvia gravity drip or infusion pump

*Determined by medical status, feeding route andvolume, and nutritional goals


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Consideration of Physical Propertiesof Enteral Formulas

Residue

Viscosity

Size of tube is important

Osmolality: consider protein source

Intact (do not affect osmolality)soyisolates; sodium or calcium casein;lactalbumin

Hydrolyzed (more particles)peptides orfree amino acids


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Renal Solute Load

Normal adult tolerance is 1200 to 1400mOsm/L

Infants and renal patients maytolerate less


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Lower Osmolality

Large (intact) proteins

Large starch molecules


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Higher Osmolality

Hydrolyzed protein or amino acids

Disaccharides


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Tolerance

Signs and symptoms:

Consciousness

Respiratory distress

Nausea, vomiting, diarrhea

Constipation, cramps

Aspiration

Abdominal distention


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Tolerancecontd

Other signs and symptoms

Hydration

Labs

Weight change

Esophageal reflux

Lactose/gluten intolerances

Glucose fluctuations


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How to Determine Energy andProtein

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


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Energy in Formulas

1 to 1.2 kcal/ml = usual concentration

2 kcal/ml = highest concentration


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Protein

From 4% to 26% of kcal is possible

14% to 16% of kcal is usual

18% to 26% of kcalconsidered to behigh-protein solution


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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% to85% water

Elderly: consider 25 ml/kg with renal, liver,

or cardiac failure; or consider 35 ml/kg ifhistory of dehydration


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Sources of Fluid (Free Water)

Liquids

Water in food

Water from metabolism

With tube feeding, nurse will flush tube withwater about 3 times dailyinclude this

amount in estimated needsExample: flush with 200 cc tid


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Administration: Feeding Rate

Continuous method = slow rate of 50 to 150ml/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 mlseveral time a day (push is not desired)


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French UnitsTube Size

Diameter of feeding tube is measured inFrench units

1F = 33 mm diameter

Feeding tube sizes differ for formula typesand administration techniques.


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Examples of Special Formulas

Pediatrics

Low residue

High protein

Volume restriction

Diabetic

Pulmonary/COPD


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Enteral Nutrition Monitoring


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Routes of Parenteral Nutrition

Central access

TPN both long- and short-term placement

Peripheral or PPN

New catheters allow longer support viathis method limited to 800 to 900 mOsm/kgdue to thrombophlebitis


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PPN vs. TPN

Kcal required(10% dextrose max. PPN conc.)

Fluid tolerance

Osmolarity

Duration

Central line contraindicated

Venous Sites from Which the Superior Vena Cava


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Venous Sites from Which the Superior Vena CavaMay Be Accessed


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AdvantagesParenteral Nutrition

Provides nutrients when less than2 to 3 feet of small intestine remains

Allows nutrition support when GIintolerance prevents oral or enteralsupport

Indications for Total


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Indications for TotalParenteral Nutrition

GI non functioning

NPO >5 days

GI fistula Acute pancreatitis

Short bowel syndrome

Malnutrition with >10% to 15 % weight loss

Nutritional needs not met; patient refuses food


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Contraindications

GI tract works

Terminally ill

Only needed briefly (


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Calculating Nutrient Needs

Avoid excess kcal (> 40 kcal/kg)

Adults

kcal/kg BW

Obeseuse desired BMI range or anadjusted factor


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Adjusted Body Weight

Adjusted IBW for obesity

Female:

([actual weightIBW] x 0.32) + IBWMale:

([actual weightIBW] x 0.38) + IBW


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Parenteral Components

Carbohydrate

glucose or dextrose monohydrate

3.4 kcal/g

Amino acids

3, 3.5, 5, 7, 8.5, 10% solutions

Fat10% emulsions = 1.1 kcal/ml

20% emulsions = 2 kcal/ml


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Protein Requirements

1.2 to 1.5 g protein/kg IBWmild or moderate stress

2.5 g protein/kg IBWburns or severe trauma


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Carbohydrate Requirements

Max. 0.36 g/kg BW/hr

Excess glucose causes:

Increased minute ventilationIncreased CO2 production

Increased O2 consumption

Lipogenesis and liver problems


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Lipid Requirements

4% to 10% kcals given as lipid meetsEFA requirements; or 2% to 4% kcalsgiven as lineoleic acid

Usual range 25% to 35% max. 60% ofkcal or 2.5 g fat/kg


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Other Requirements

Fluid30 to 50 ml/kg

Electrolytes

Use acetate or chloride formsto manage acidosis or alkalosis

Vitamins

Trace elements

Calculating the Osmolarity of a


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Calculating the Osmolarity of aParenteral Nutrition Solution

1. Multiply the grams of dextrose per liter by 5.Example: 50 g of dextrose x 5 = 250 mOsm/L

2. Multiply the grams of protein per liter by 10.

Example: 30 g of protein x 10 = 300 mOsm/L

3. Fat is isotonic and does not contribute toosmolarity.

4. Electrolytes further add to osmolarity.Total osmolarity = 250 + 300 = 500 mOsm/L


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Compounding Methods

Total nutrient admixture of amino acids,glucose, additives

3-in-1 solution of lipid, amino acids,glucose, additives


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Administration

Start slowly(1 L 1st day; 2 L 2nd day)

Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV)

Cyclic give 12 to 18 hours per day


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Monitoring and Complications

Infection

Hemodynamic stability

Catheter care

Refeeding syndrome


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Refeeding Syndrome

Hypophosphatemia

Hyperglycemia

Fluid retention

Cardiac arrest


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Monitor

Weight(daily)

Blood

DailyElectrolytes (Na+, K+, Cl-)GlucoseAcid-base status

3 times/weekBUNCa+,PPlasma transaminases


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Monitorcontd

BloodTwice/week

AmmoniaMg

Plasma transaminasesWeekly

HgbProthrombin time

ZnCuTriglycerides


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Monitorcontd

Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)

Other:Volume infusate (daily)Oral intake (daily) if applicable

Urinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)


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Problems

PPNSite irritation

TPN

1. Catheter sepsis2. Placement problems3. Metabolic


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Pediatric

EnergyInfant

50 to 60 kcal/kg/day maintenance70 to 120 kcal/kg/day growth

Child >1yrBEE

1to 8 yrs 70 to 100 kcal/kg/day8 to 12 yrs 60 to 75 kcal/kg/day

12 to 18 yrs 45 to 60 kcal/kg/dayInjury factors1.25 mild stress1.50 nutritional depletion2.00 high stress


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Pediatriccontd

Protein:Infant

2.4 to 4 g/kg/day 1 year1 to 8 years 1.5 to 2.0 g/kg/day8 to 15 years 1.0 to 1.5 g/kg/day


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Pediatriccontd

CarbohydrateInfant preterm:

4 to 6 mg/kg/minute begin rateTerm infants:

8 to 9 mg/kg/minute begin rate

FatInfants:

0.5 to 1.0 g/kg/day min for EFA needs2 to 3 g/kg/day max

Vitamins and minerals:See tables in textbook


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Pediatriccontd

Fluid and electrolytesInfant:LBW 125 to 150 ml/kg/day

2 to 4 mmol/kg/day for electrolytes

Other infants and children


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Document in Chart

Type of feeding formula and tube

Method (bolus, drip, pump)

Rate and water flush

Intake energy and protein

Tolerance, complications, andcorrective actions

Patient education

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