Enteral Nutrition

Hasanul Arifin

BAGIAN ANESTESIOLOGI DAN REANIMASI FAKULTAS KEDOKTERAN USU MEDAN

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ENTERAL NUTRITION SUPPORT

I.Prerequisites

a functioning gastrointestinal tract at least 100 cm of small bowel condition of bowel adequate for absorption patient incapable of adequate oral intake

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II. Advantages
less potential risk of infection, metabolic complication favours intestinal integrity and function maintains GI tract functions [ IgA, hormones, GALT ] promotes gut motility reduces bacterial translocation from the gut less expensive product, delivery, monitoring

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 evidence based indications

existing malnutrition or risk of malnutrition poor appetite or anorexia prolonged fasting [>7 days] supplementation of insufficient oral intake for > 7 days

III. Indications

pragmatic indications
severely stressed patients expected to be unable to eat for 5-7 days or more severe trauma , burn [following] small bowel resection resumption of GI activity & preparation for oral 7/25/2013 feeding

IV. Contra Indication

Obstruction of GI tract Protracted vomiting or diarrhea High output fistulas [> 500 ml] Diffuse peritonitis or ileus Acute bowel ischemia / gut necrosis Severe acute pancreatitis Severe short bowel syndrome [<100 cm]
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EVALUATE ENERGY + PROTEIN NEED

FUNCTIONAL GI-TRACT ? NO CONTRAINDICATIONS TO EN ? YES NO
Highly catabolic state (major trauma, burn surgery,septic shock)?

YES

NO
Are conditions to start EN present? YES NO

Gastric residual volume >200ml

Increase flow rate by 250500 ml/day

Start PN

Monitor gastric residual volume 2/day

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Reduce infusion rate by 50% 4-6h, then progressive increase over 24-48 h

Start continuous EN at 500 ml/24h

Monitor gastric residual volume

Administer prokinetics(cisapride, metoclopramide, erythromycin)

Start PN and reassess daily for conditions to 8 start EN

Jolliet.P et al, Enteral nutrition in intensive care patients : a practical approach. Intensive Care Med 1998;24(8):848-859

EN, administered by
Nasoenteric route Percutaneous route

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Nasoenteric route

Nasogastric, Nasoduodenal, Nasojejunal 2 - <4 weeks small diameter[6-12 Fr/Ch] Silicone, polyurethane [PUR], radioopaque stomach 90 cm, duodenum 110 cm, jejunum 120 cm prokinetic R/ metoclopropamide, erythromycine, cisapride inner stylets proper placement in stomach pH specimen aspirated <5.0
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Nasoenteric Feeding Tube Composition

PVC
Ease to insertion To stiff for comfort

Silicone
To soft

PUR
Adequate

Ability to aspirate gastric content Patient comfort Durability/strength

Excellent Very poor Strong but brittle

Poor to fair Excellent Breaks easily

Good Good Excellent/strong

Peggi Guenter: Delivery System Administration of Enteral Nutrition, in Rombeau JL, Clinical Nutrition, Enteral and Tube Feeding,1997:244.
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Naso Gastric Tube

(NGT)

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Percutaneous route

PEG, PEJ, combined nasogastric jejunal PEG, procedure of choice for ICU patients. [ 4-6 weeks] 9-24Fr Relative CI, ascites, gastric cancer, gastric ulcer, previous laparotomy, coagulation disorder. Post-pyloric feeding PEJ.

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PEG

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Classification of Tube Feeding Formulas Polymeric

Polysaccharida, maltodextrin [60-70%NPC] MCT, LCT [30-40% NPC] Whole protein, partially hydrolyzed [35-40g/L formula] Isotonic [1.0-1.5 k.cal/ml] standardised, iso osmotic (approximately 300 mOsm/L)

R/ Panenteral, Nutren,

fiber enriched . R/ Nutren Fibre

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polymeric specialized for patients Diabetes, R/ Nutren

Diabetes

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Elemental

Chemically defined Glucose, oligosaccharides Crystalline amino-acids, peptide replace protein Medium Chain Triglyceride Specialized enteral formula [hepatic failure, renal failure, stress-hypercatabolic ] BCAA, Glutamine

R/ Peptivariant-2000 R/ Peptamen
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Immune enhanced

Arginine, Glutamine, Ornithine -ketoglutarate [OKG] RNA Omega-3-fatty acids Nucleotide

R/ NEOMUNE

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Manufactured products Immune Enhanced

Alitra Impact
Q
units
Energy Protein Free-Gln Arginine Nucleotide kcal/L g/L g/L g/L g/L 1000 52.5 15.5 4.5 0 1010 56 0 12.8 1.3 1300 66.6 12.2 8.1 0 1250 75 13 9 0

Perativ Stresson
e

Lipids

Safflower oil
MCT

Palm oil
Safflower oil Menhaden oil 3.3

Canola oil
Corn oil MCT 1.24

Vegetable oil
Fish oil Vegetable, fish 1.1

Omega-3-FA

g/L

0.02

Antioxidants
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yes

yes

yes

yes
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Administering tube feeding

Intermittent (bolus)
naso gastric tube, gastrostomy
head up position 300 start gastric feeding of 150-200ml over 20-40 minutes,

increase by 50-100ml each feeding as tolerated to goal

followed by 30 ml warm water flush check residuals before next feeding (up to half) for sign of intolerance (diarrhea, vomiting), reduce to last tolerated step, evaluate clinically.
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Continuous (drip infusion)

Intragastric, duodenal, jejunal Start at 30-50 ml/hr isotonic formula Increase by 30-50/hr every 6-8 hours to goal Maximum 100-150ml/hr Most tube fedings are tolerated at full strength Reduce risk ( retention, aspiration)

followed by 30 ml warm water flush for sign of intolerance (diarrhea, vomiting), reduce to last tolerated step, evaluate clinically.
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Continuous drip infusion

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EN + PEN

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Monitoring,

Metabolic, gastrointestinal, mechanical assessment Routine dayli evaluation of intake,output, weight Acutely ill patients require daily to weekly serum electrolyte, glucose, BUN, Cr, Ca++, Mg++, Ph. Stable patients require weekly-monthly laboratory studies Elevate head of bed 300 during feeding Check stomach for high residuals to minimize aspiration risk
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Complications,

Metabolic : overhydration, dehydration, undernutrition, hyperglycemia, electrolyte imbalance Gastrointestinal : nausea, vomiting, constipation abd. discomfort, diarrhea Mechanical : misplaced, clogged feeding tube airway, GI tract injury with NG/NJ tube placement. Infectious : peritonitis, exit site infection, sinusitis, aspiration pneumonia
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Terima kasih

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