Williams’ 11th

EDITION

Essentials
of Nutrition
and Diet Therapy
Eleanor D. Schlenker, PhD, RD
Professor and Extension Specialist
Department of Human Nutrition, Foods, and Exercise
College of Agriculture and Life Sciences
Virginia Polytechnic Institute and State University
Blacksburg, Virginia

Joyce Gilbert, PhD, RD

Professor and Executive Director
Department of Family and Consumer Sciences
College of Health and Human Development
California State University, Northridge
Northridge, California
3251 Riverport Lane
St. Louis, Missouri 63043

WILLIAMS’ ESSENTIALS OF NUTRITION & DIET THERAPY, ISBN: 978-0-323-18580-6

ELEVENTH EDITION
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Library of Congress Cataloging-in-Publication Data

Schlenker, Eleanor D., author.
╇ Williams’ essentials of nutrition and diet therapy / Eleanor D. Schlenker, Joyce Gilbert. — Eleventh edition.
â•…â•… p. ; cm.
╇ Essentials of nutrition and diet therapy
╇ Preceded by Williams’ essentials of nutrition and diet therapy / Eleanor D. Schlenker, Sara Long Roth.
10th ed. c2011.
╇ Includes bibliographical references and index.
╇ ISBN 978-0-323-18580-6 (pbk. : alk. paper)
╇ I.╇ Gilbert, Joyce, author.╅ II.╇ Title.╅ III.╇ Title: Essentials of nutrition and diet therapy.
╇ [DNLM: 1.╇ Nutritional Physiological Phenomena.â•… 2.╇ Diet Therapy.â•… 3.╇ Nutritional Sciences–methods.╇ QU
145]
╇ RM216
╇ 613.2–dc23
2014027630

Director, Traditional Education: Kristin Geen

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Nutrition Support: Enteral and
EVOLVE WEBSITE
http://evolve.elsevier.com/Williams/essentials/
OUTLINE
Nutrition Assessment
Enteral Nutrition Versus Parenteral Nutrition
Enteral Tube Feeding in Clinical Nutrition
Enteral Tube Feeding Formulas
Enteral Tube Feeding Delivery Systems
Monitoring the Tube-Fed Patient
In this chapter, we look at alternate modes of feeding to provide
nutrition support for patients with special needs. We examine
ways of feeding when the gastrointestinal (GI) tract can be
used—enteral nutrition (EN) given orally or through a feeding
tube. Then we review nutrient feeding directly into a vein when
the GI tract cannot be used—parenteral nutrition (PN).
Malnutrition, preexisting and hospital-induced, is a serious
concern in hospitalized patients, especially those with critical
illness or injury. Nutrition care provided by a skilled nutrition
support team or clinician can have a positive effect on patient
survival and recovery. This chapter will examine EN and PN
support formulas, solutions, and delivery systems for use in
hospital and home.
NUTRITION ASSESSMENT
Nutrition Support and Degree of Malnutrition
It is an easier task to maintain nutrition than to replenish
body stores from malnutrition. The effect of starvation on the
body, even during relatively brief periods, is well docu-
mented.1 The small amount of glycogen stored in the liver is
a crucial immediate energy source. Glycogen breakdown for
fuel begins 2 to 3 hours after a meal, and glycogen stores are
depleted after 30 hours of fasting in the absence of metabolic
CHAPTER
19â•…
Parenteral Nutrition
Pamela Charney
Parenteral Feeding in Clinical Nutrition
Parenteral Solutions
Parenteral Nutrition Delivery System
Home Nutrition Support
HEALTH PROMOTION
Troubleshooting Diarrhea in Tube-Fed Patients
stress. Release of amino acids from body tissue proteins
begins after 4 to 6 hours of fasting to provide a source of
blood glucose. In addition, fatty acids are mobilized from the
body’s adipose tissues to provide keto acids as a principal fuel
for heart, brain, and other vital organs. As adaptation to
starvation occurs, the body relies less on amino acids from
protein for fuel and uses more ketones from fat to meet
metabolic needs. This reduces nitrogen losses and preserves
lean body mass. During critical illness this adaptation to
insufficient energy to meet needs does not occur. Severely ill
patients rely heavily on large amounts of glucose and protein
for fuel. They often have elevated insulin levels, which inhibit
the mobilization of fat for energy production, and thus
increase reliance on amino acids from protein with a urinary
nitrogen loss of 10 to 15╯g/day or more that continues
unchecked. Critical illness can lead to severe depletion of lean
body mass. Nutrition provided during critical illness reduces
but does not reverse the process.
For example, two healthy people are hiking in the moun-
tains and get lost. They have a limited supply of food but
adequate water available from mountain streams. Hiker #1 is
severely injured in a fall while the two are searching for the
way back to civilization. Both have an inadequate food supply
to meet their energy needs. Hiker #2 will initially use glycogen
419
420 PART 3â•… Introduction to Clinical Nutrition
stores followed by breakdown of lean body mass and fat for
energy needs. However, after several days the body will
decrease its use of protein for energy and start relying on fat
so that lean body mass is preserved as long as possible. This
is the adaptation to starvation. Hiker #1 will not adapt to
starvation. He will continue to use protein for energy and rely
much less on fat for fuel and thus will lose more lean body
mass during the period of inadequate energy supply than
Hiker #2.
Any medical treatment has less chance of success if the
patient is malnourished. The patient who becomes malnour-
ished during hospitalization (iatrogenic malnutrition) has
been referred to as the skeleton in the hospital closet, with
several reports of general malnutrition among hospitalized
patients.2-6 Lack of adequate nutrition to meet metabolic
demands is increasingly recognized as a serious concern in
medical and surgical patients. Malnutrition is the end result
when nutrient intake does not meet nutrient needs over some
period of time. Braunschweig and colleagues6 reported that
as many as 54% of patients admitted to the hospital were
malnourished, and 31% of these patients declined nutrition-
ally during hospitalization.
In addition, many medical and surgical diagnoses are asso-
ciated with nutritional risk through impact on nutrient
requirements, ability to consume nutrients, or by changing
nutrient metabolism. Deterioration of a patient’s nutritional
status during hospitalization may contribute to increased
length of hospital stay, development of comorbidities, and
increased cost.6 Persons with underlying chronic disease or
traumatic injury, and older adults are particularly at risk.
Thus assessment, monitoring, and reassessment of nutri-
tional status become important parts of overall care, espe-
cially for hospitalized patients (see Chapter 16). For the
severely malnourished patient, especially those facing prob-
lems such as organ failure or extensive surgery, adequate and
consistent provision of nutrition support is indicated. The
guiding principle for provision of nutrition support is “if the
gut works, then use it.” Studies have shown when patients are
fed appropriately enterally rather than parenterally, they
experience fewer infectious complications and shorter lengths
of stay, and recover more rapidly.7-9
Regulatory agencies such as The Joint Commission require
that nutrition screening be completed within 24 hours of
hospital admission. The purpose of the initial nutrition
screen should be to identify potential nutrition diagnoses,
including malnutrition. When risk for nutrition problems is
identified through the admission nutrition screen, the regis-
tered dietitian (RD) should be consulted.
The RD conducts the initial nutrition assessment and per-
forms ongoing monitoring of nutritional status. Initial assess-
ment data supply the necessary basis for (1) identifying
patients who require nutrition intervention, (2) determining
an appropriate nutrition support route (i.e., enteral or par-
enteral), (3) calculating the patient’s nutrient requirements,
(4) determining specific formulations to meet those require-
ments, and (5) identifying measurable nutrition-related out-
comes for determining if the nutrition care plan is appropriate
and effective. Once therapy begins, careful monitoring main-
tains optimal therapy and discourages metabolic, septic, and
GI complications.
Guidelines for Nutrition Assessment
Nutrition assessment is done through a standard approach
and includes six key parameters: (1) evaluation of nutrient
intake and adequacy, (2) nutrition-focused physical assess-
ment, (3) biochemical laboratory data, (4) anthropometrics,
(5) comprehensive review of medical and surgical histories,
and (6) nutrition diagnosis.10,11 Nutrition assessment tech-
niques and parameters are described in detail in Chapter 16.
However, standard nutrition assessment parameters are
adversely affected by critical illness and inflammatory
response. Weight is often affected by fluid status and may no
longer reflect usual or current body weight. However, expe-
rienced nutrition support RDs are able to evaluate the
patient’s “dry weight” by an accounting of the fluid volume
infused (1╯L of water weighs 1╯kg). There are no laboratory
values that accurately reflect nutrition status. Clinicians must
rely primarily on subjective global assessment (Box 19-1) and
astute clinical judgment to perform and interpret assessment
of nutritional status.5,12 Subjective global assessment focuses
on history and physical examination.5 This technique elimi-
nates the ambiguity and nonspecific, nonsensitive nature of
laboratory values during critical illness and inflammation.
BOX 19-1 SUBJECTIVE GLOBAL
ASSESSMENT
COMPONENTS
History
• Change in weight
• Change in dietary intake
• Gastrointestinal (GI) symptoms
• Functional capacity
• Nutritional requirements of disease
Physical Assessment
• Loss of subcutaneous fat
• Muscle loss
• Fluid retention
• Ankle and sacral edema
• Ascites
Data from Detsky AS, McLaughlin JR, Baker JP, et╯al: What is
subjective global assessment of nutritional status? JPEN J Parenter
Enteral Nutr 11(1):8, 1987. Reprinted with permission of SAGE
Publications.
KEY TERMS
enteralâ•… A feeding modality that provides nutrients, either
orally or by tube feeding through the gastrointestinal (GI)
tract.
parenteralâ•… A feeding modality that provides nutrient solu-
tions intravenously rather than through the gastrointestinal
(GI) tract.
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition
History
History includes all aspects of the patient’s health: weight
change, nutrient intake, GI function and symptoms, func-
tional capacity, and diagnosis and its nutritional effect. The
clinician should identify whether the patient has experienced
an intentional or nonintentional weight change from normal
or usual weight and the time frame during which the weight
change occurred. Quantifying weight loss is not always easy,
particularly if the patient has lost lean body mass but weight
is unchanged because the patient is retaining fluid as occurs
with end-stage liver, heart, and kidney diseases. Current or
actual body weight (ABW) and height are interpreted accord-
ing to changes from usual body weight (UBW) and the
percent of recent weight change:
Percent UBW = ABW ÷ UBW × 100
Percent weight change = [(UBW − ABW ) ÷ UBW ] × 100
The amount of recent weight change is compared with
values associated with malnutrition (Table 19-1).
Changes in appetite and dietary intake must be assessed
to identify overall nutrient adequacy of the diet and potential
contributing factors for reported weight loss. It is important
to identify diet modifications observed and nutritional
supplements consumed by the patient. The clinician must
verify whether nutritional supplements are being taken in
addition to meals or used as a meal replacement. It should be
remembered that it is not enough to simply order these sup-
plements: They must be consumed, and when consumed they
must not take the place of food. GI function determines the
ability to assimilate nutrients. The presence of nausea, vomit-
ing, diarrhea, and anorexia inhibits nutrient intake and avail-
ability. Assessment of functional capacity of the patient
determines whether the patient can perform activities of daily
living (ADLs), completely or in part, or if the patient is bed-
ridden and totally dependent on others for care. Medical and
surgical history entails examination of the past and current
medical problems and enables the clinician to identify poten-
tial risks for nutrient inadequacies, deficiencies, excesses, and
toxicities.
TABLE 19-1 CATEGORIZATION OF
SEVERITY OF WEIGHT
LOSS BY PERCENTAGE OF
WEIGHT LOST OVER TIME
TIME SIGNIFICANT SEVERE WEIGHT
PERIOD WEIGHT LOSS (%) LOSS (%)
1 week 1-2 >2
1 month 5 >5
3 months 7.5 >7.5
6 months 10 >10
Modified from the American Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.): Nutritional and metabolic assessment of the
hospitalized patient. JPEN J Parenter Enteral Nutr 1(1):11, 1977.
Reprinted with permission of SAGE Publications.
421
Physical Examination
During the physical assessment the clinician looks for signs
of muscle and fat wasting. Inspection of the upper body can
identify temporal, clavicular, and torso wasting of skeletal
muscle mass and subcutaneous fat. Signs of edema and ascites
indicate inability to keep fluid in the vascular space with
subsequent interstitial fluid accumulation. Physical signs and
symptoms are then correlated to the patient’s disease process
and current medical condition.
Basal Energy Expenditure
Over 200 different formulas have been proposed for use in
estimating energy requirements. At this time, if indirect calo-
rimetry is not available the Mifflin-St. Jeor regression equa-
tion is recommended for use in most care settings. Daily
energy requirements are estimated by combining basal energy
expenditures (BEEs), disease and injury energy needs, and
physical activity (see Chapter 8).
The Mifflin-St. Jeor equation uses measures of weight in
kilograms, height in centimeters, and age in years to calculate
resting energy expenditure (REE):
Women: REE = (10 × wt) + (6.25 × ht) − (5 × age) − 161
Men: REE = (10 × wt) + (6.25 × ht) − (5 × age) + 5 14
For example, the REE for a 35-year-old woman, weighing
60╯kg (132╯lb), standing 165╯cm (5 feet 5 inches) is calculated
as follows:
(10 × 60) + (6.25 × 165) − (5 × 35) − 161
= 600 + 1031− 175 − 161 = 1295 kcal/dayy
The term REE is often used interchangeably with BEE in
discussing basal energy needs. In general, energy provision
to critically ill patients should not exceed 20% beyond the
BEE/REE. However, metabolic conditions such as severe
burns or head injury create energy needs up to 50% to 100%
beyond BEE.
Energy requirements for hospitalized patients on nutri-
tion support vary with amount of metabolic stress but
generally range from 20 to 35╯kcal/kg.15 Regardless of the
calculation used to estimate energy expenditure, it is impor-
tant to monitor the effect of nutrients provided to determine
changes needed to maintain or replete the patient. Energy and
nutrients are adjusted based on patient tolerance and desire
versus actual response to nutrient provision. Remember that
estimations of energy requirements are simply that—an esti-
mation. Frequent follow-up and feeding adjustments ensure
that desired therapeutic goals are met more so than which
formula is utilized to estimate requirements.
The more malnourished a patient is, the more carefully
resumption of nutrition should be done. Refeeding syndrome
is a life-threatening response to overaggressive provision of
energy to a patient who has been chronically starved. Hall-
mark symptoms of refeeding are a shift of electrolytes from
blood into the cell, resulting in decreased blood levels of
422 PART 3â•… Introduction to Clinical Nutrition
potassium, phosphorus, and magnesium, along with increased
blood glucose levels and fluid retention.16 The end result can
be cardiac collapse and death. Refeeding syndrome is entirely
preventable through early identification of risk combined
with appropriate monitoring of serum electrolyte levels with
replacement as needed.
Critically ill patients with major trauma, sepsis, and
inflammation demonstrate catabolism (i.e., breakdown of
body tissue) resulting in a net loss of body mass. When
protein is broken down, the nitrogen component of amino
acids is released and excreted in urine. Nitrogen lost in urine
can be as high as 15 to 30╯g over 24 hours. This can result in
a negative nitrogen balance if the patient is losing more nitro-
gen in urine than is provided from protein in the diet. Cata-
bolic periods with losses of lean body mass are inevitable after
trauma and extensive surgery. The catabolic process increases
nutrient demand and requirements. Initiating nutrition
support in these patients reduces, but does not eliminate,
negative nitrogen balance that occurs after traumatic injury
or critical illness.
Nitrogen Balance
Nitrogen balance studies are calculations that estimate the
amount of catabolism. The patient’s intake of protein (nitro-
gen) is subtracted from nitrogen output through urinary and
insensible losses:
Nitrogen balance = Nitrogen intake − Nitrogen loss
Nitrogen intake = Protein intake ÷ 6.25*
Nitrogen loss = Urinary urea nitrogen + 4†
For example, a patient receiving 50╯g of protein per day in
an enteral tube feeding is getting 8╯g of nitrogen per day (50╯g
÷ 6.25 = 8╯g). If that individual’s nitrogen losses are 10╯g per
24 hours (6╯g in urine per nitrogen balance study + 4╯g of
insensible losses), then the patient’s nitrogen balance is
−2╯g/24 hours. Increasing protein in the enteral tube feeding
to more than 62.5╯g protein per day will result in a positive
nitrogen balance.
However, nitrogen balance calculation is not accurate with
renal failure or retained nitrogen such as elevated blood urea
nitrogen (BUN). Other sources of nitrogen such as blood
products, as well as the loss of nitrogen from wounds, stool,
nasogastric suction, and bleeding, must also be taken into
account when calculating nitrogen balance. The 4╯g of insen-
sible nitrogen loss may not be an accurate estimate and could
affect the accuracy of the results. Measurement of urinary
urea nitrogen requires an accurate 24-hour urine collection.
Accurate 24-hour urine collections are very difficult to obtain
in clinical settings, even in patients who have urinary cathe-
ters in place. Because of this and the expense associated with
measurement of urinary urea nitrogen (UUN), routine use
of nitrogen balance cannot be recommended in clinical
practice.
*6.25╯g of protein yields 1╯g nitrogen.
†
Estimated insensible losses of nitrogen.
Hepatic Proteins as Nutrition Indicators
In the past, serum levels of the hepatic transport proteins,
albumin, transferrin, and prealbumin, were used to deter-
mine the patient’s nutritional status. During critical illness,
hepatic production of albumin, transferrin, and prealbumin
is decreased in favor of increased production of acute phase
reactants required for survival.12,17 A decreased serum value
of albumin, prealbumin, or transferrin therefore signifies an
inflammatory process (or how sick the patient is) and does
not provide information about the patient’s nutritional status
or response to nutrition therapy. These proteins are better
used as prognostic indicators of the patient’s risk of compli-
cations (morbidity) and death (mortality). It is no longer
recommended that serum hepatic transport protein levels be
used to assess nutritional status or to monitor response to
nutrition support.
Management of Nutrition Support Patients
Management of nutrition support is ideally performed by an
official interdisciplinary nutrition support committee or
team composed of designated members from the depart-
ments of medicine, surgery, nutrition, nursing, and phar-
macy.18 Each team member should be certified in nutrition
support by an accrediting body such as the National Board
of Nutrition Support Certification and the Board of Pharma-
ceutical Specialties. The American Society for Parenteral and
Enteral Nutrition (A.S.P.E.N.) has developed standards of
practice for nutrition support professionals and interdisci-
plinary nutrition support competencies.19-23 However, in
many facilities, nutrition support management is overseen
by an informal collection of interested clinicians, a sole nutri-
tion support practitioner, or no one person in particular.
Standards of The Joint Commission and the Accreditation
Manual for Hospitals (AMH) have focused on key multidis-
ciplinary processes that ensure performance of nutrition
screening and assessment to promote quality patient out-
comes.24 (For additional considerations surrounding nutri-
tion support, see the Focus on Culture box, “What’s Religion
Got to Do with It?”)
Baseline nutrition data obtained before starting nutrition
support provide a means of measuring effectiveness of treat-
ment. At designated periods during therapy, certain tests are
repeated to monitor the patient’s course and reduce meta-
bolic complications. Specific protocols vary in different
medical centers. However, a general guide for standard moni-
toring data is summarized in Box 19-2.25
Generally, clinicians give primary importance to the fol-
lowing three major monitoring parameters: (1) serial weights
to determine the adequacy of total energy provision and to
monitor fluid status, (2) physical examination for micronu-
trient adequacy and changes in body fat and muscle mass,
and ultimately (3) improvement in functional status.
All baseline and monitoring data are recorded in the
patient’s chart, along with all enteral and parenteral solution
orders.
No evidence-based “rules” exist for the time to start nutri-
tion support with either EN or PN. Determination of when
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition
╇ FOCUS ON CULTURE
What’s Religion Got To Do with It?
“That was not a natural death. It was an imposed death,” said
Cardinal Renato Martino, a top Vatican official. “When you
deprive somebody of food and water, what else is it? Nothing
else but murder.” In this impassioned statement, the cardinal
was referring to the landmark battle over the life of Terri
Schiavo after her death after nearly 2 weeks without any nutri-
tion support. Over 15 years had passed since Terri Schiavo had
suffered severe brain damage stemming from heart failure and
had relied on EN for survival ever since. The legal decision to
stop her tube feeding created a national uproar and sparked
many debates over end-of-life issues, including nutrition
support. The Catholic Church fervently opposed the legal action
taken and was especially vocal in the events surrounding Terri
Schiavo’s death because she was Catholic.
What role does religion have in issues such as nutrition
support? In this section we will encapsulate beliefs of three
religions, focusing on end-of-life issues, particularly nutrition
support.
Catholicism
Because Catholics believe they are stewards of their bodies
and life is to be respected, the act of withholding nutrition
support is not something to be taken lightly. However, bodily
life is not to be maintained at all costs. The late Pope John Paul
II wrote: “Certainly there is a moral obligation to care for
oneself and allow oneself to be cared for, but this duty must
take account for concrete circumstances. It needs to be deter-
mined whether the means of treatment available are objec-
tively proportionate to the prospects for improvement.”
In short, withdrawal of nutrition support is not condemned,
but rather only recommended when quality of life is so low
nutrition is of absolutely no benefit. Although it is hard to know
where the point of “no benefit” is, it is the duty of a Catholic
to promote a social order in which a certain level of responsibil-
ity exists for those who are marginalized or in a vegetative
state. Each case merits special consideration, and in most
cases nutrition is considered a basic form of care likened to
warmth and cleanliness.
Judaism
According to Judaism, life possesses an intrinsic value as a
divine gift of creation. As in Catholicism, humans are thought
to be only a temporary steward of the body and therefore must
treat the body with utmost respect and sensitivity. Jewish law
mandates humans must do everything in their power to heal
themselves when ill and must also strive to save the lives of
others. This obligation, however, applies only to those thera-
pies that have a reasonable chance of success, and although
some believe tube feeding is equivalent to medical treatments,
Jewish tradition disagrees with this opinion. According to
to initiate nutrition support depends on the patient’s nutri-
tional status and the anticipated time period before oral diet
can be resumed and tolerated. The A.S.P.E.N. guidelines7 rec-
ommend that nutrition support should be considered when
the patient has had an inadequate oral intake for 7 to 14 days
423
Jewish authorities, nutrition in any form is a basic human need
and should be provided to all patients unless feeding itself
causes suffering. Consequently, Jewish law further accentu-
ates feeding must be done in a kind and compassionate
manner, emphasizing the importance this religion places on
nourishment.
Islam
Not unlike the other religions mentioned in this section, in
Islam humans are thought of as stewards of their bodies,
which are viewed as a gift from God. Sanctity of life is a
monumental principle, and every moment of life is deemed
precious and must be preserved. Even so, death is believed
to be a natural part of life, and treatment does not have to
be provided if it merely prolongs the final stages of a terminal
illness. Nutrition support—especially EN—is considered part
of basic care rather than a treatment; therefore it is a
religious obligation to provide nourishment unless such an
act shortens life.
Religion and end-of-life issues like nutrition support are
complicated and sensitive matters that must be approached
with understanding and tolerance. People from different reli-
gious backgrounds can have varying views on this subject that
can drastically affect the choice of care provided. The Terri
Schiavo case brought to life a plethora of issues that will not
likely be resolved any time soon; however, when dealing with
nutrition support cases, it is important to consider the implica-
tions that the patient’s religion can have for your decisions
and actions.
Bibliography
Associated Press: Vatican: Schiavo’s death “cruel.” Fox News
March 31, 2005. (News broadcast.)
Clarfield AM, Gordon M, Markwell H, et╯al: Ethical issues in
end-of- life geriatric care: the approach of three monotheistic
religions—Judaism, Catholicism, and Islam. J Am Geriatr
Soc 51:1149, 2003.
Cooley M: Faith, ethics help many in agonizing dilemma. The
Spokesman-Review A1, 2005.
Huggins C: Survey finds physicians willing to allow patients’
religion to trump medical advice, New York, August 9, 2005,
Reuters Health. (News release.)
Jotkowitz A, Clarfield A, Slick S: The care of patients with
dementia: a modern Jewish ethical perspective. J Am Geriatr
Soc 53:881, 2005.
Sunshine E: Sunshine, Truncating Catholic tradition: Florida
bishops avoid full consideration of ethical issues in Schiavo
case. Natl Cathol Report 41:23, 2005. from: <http://www
.natcath.com/NCR_Online/archives2/2005b/040805/
040805k.php>. Retrieved December 22, 2005.
or the patient’s oral intake is anticipated to remain inade-
quate for 7 to 14 days. A 5- to 10-day timeline is recom-
mended for critically ill patients. Other guidelines available
to identify when to feed are the “rule of five” and amount of
weight loss. The rule of five states that if a patient has had no
424 PART 3â•… Introduction to Clinical Nutrition

food for 5 days and is unable to tolerate an oral diet for an for nutrition support. Figure 19-1 provides an algorithm for
additional 5 days, nutrition support should be considered to determining the route of nutrition support.7
reduce the risk of developing malnutrition. The weight-loss PN is associated with serious complications, as shown in
rule stratifies patients according to the percentage of weight Box 19-3. Reliance on PN when the GI tract is functional can
loss of their usual total body weight over a designated period contribute to disuse of the GI tract with subsequent bacterial
(see Table 19-1). Patients who have undergone severe weight overgrowth, hepatic abnormalities, deterioration of GI integ-
loss and are unable to tolerate oral nutrition for 5 to 7 days rity with subsequent migration of intestinal bacteria into the
or longer are candidates for nutrition support. systemic circulation, and sepsis. Patients reliant solely on
PN are at risk for septic and hepatic complications that can
ENTERAL NUTRITION VERSUS
PARENTERAL NUTRITION
BOX 19-3 COMPLICATIONS
Debate continues concerning evidence-based effectiveness of ASSOCIATED WITH
PN and EN support. Questions focus on what constitutes PARENTERAL NUTRITION
early EN, how to select the most appropriate enteral tube
Catheter-Related Complications
feeding formula according to each patient’s specific disease
• Air embolism
state, what is the preferred method of formula delivery, and
• Catheter embolization
which factors contribute to enteral tube feeding–related com- • Catheter occlusion
plications, such as diarrhea or respiratory problems.26,27 In all • Improper tip location
cases when the GI tract is functioning, EN support should be • Phlebitis
used to restore or maintain an optimal state of nutrition. PN • Pneumothorax
should be reserved for patients with a nonfunctional GI tract • Sepsis
or an inadequately functional GI tract that prevents the • Venous thrombosis
patient from meeting nutrient needs enterally. In some cases
Gastrointestinal (GI) Complications
the patient can take some enteral feeding, but impairment in
• Fatty liver
either digestive or absorptive capacity requires supplementa-
• Gastric hyperacidity
tion with parenteral therapy. The Veterans Affairs Coopera- • GI atrophy
tive Study showed perioperative nutrition support was • Hepatic cholestasis
beneficial for severely malnourished patients but contributed
to increased complications in mild to moderately malnour- Metabolic Complications
ished patients.28 The GI tract should always be the first choice • Acid-base imbalance
• Electrolyte abnormalities
• Essential fatty acid deficiency
• Fluid imbalance
• Glucose intolerance
BOX 19-2 CLINICAL PARAMETERS TO • Metabolic bone disease
MONITOR DURING • Mineral abnormalities
NUTRITION SUPPORT • Overfeeding
• Refeeding syndrome
Daily intake and output (I/O) • Triglyceride elevation
Daily weights
Physical examination
Temperature, pulse, respirations
Laboratory parameters:
KEY TERM
• Acid-base status
constitutive proteinsâ•… Albumin, prealbumin, transferrin.
• Blood urea nitrogen (BUN)
Plasma proteins often used to assess the response to nutri-
• Complete blood cell count (CBC)
tion support. Serum levels are nonspecific and nonsensitive
• Creatinine
to nutritional status or requirements.
• Electrolytes
• Glucose
• International Normalized Ratio (INR)
• Liver function tests
• Osmolarity, serum and urine KEY TERM
• Platelet count osmolarityâ•… The number of millimoles of liquid or solid in a
• Prothrombin time (PT) liter of solution; parenteral nutrition (PN) solutions given by
• Triglyceride level central vein have an osmolarity around 1800╯mOsm/L;
• Urinary urea nitrogen peripheral parenteral solutions are limited to 600 to
• Urine specific gravity 900╯mOsm/L (dextrose and amino acids have the greatest
• Vitamins and minerals effect on a solution’s osmolarity).
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition 425

Nutrition assessment

Diffuse peritonitis,
Functional GI tract intestinal obstruction,
intractable vomiting, ileus,
Yes No intractable diarrhea,
gastrointestinal ischemia

Enteral nutrition
Long-term Short-term
Gastrostomy Nasogastric Parenteral nutrition
Jejunostomy Nasoduodenal
Nasojejunal
GI Function Short-term Long-term or fluid restriction

Normal Compromised Peripheral PN Central PN

Standard nutrients Specialty formulas GI function returns

Nutrient tolerance Yes No

Adequate Inadequate Adequate

progress to PN supplementation progress to more
oral feedings complex diet and oral
feedings as tolerated
Progress to total
enteral feedings
FIGURE 19-1╇ Route of administration of specialized nutrition support. (Reprinted from A.S.P.E.N.
Board of Directors: Clinical pathways and algorithms for delivery of parenteral and enteral nutri-
tion support in adults, Silver Spring, Md., A.S.P.E.N, 1998, p. 5.)

contribute to morbidity and mortality. The GI tract is the
body’s largest immune organ. (To learn more about probiot-
ics and how they contribute to EN and PN, see the Evidence-
Based Practice box, “Probiotics.”) GI disease that prevents or
reduces use of the GI tract may itself contribute to adverse
effects often associated with PN. Therefore it may not be the
route of feeding, but rather the inability to use the gut that
increases infectious and metabolic complications.29 Some
adverse effects of PN may be related to inability to provide
all necessary nutrients parenterally. Parenteral solutions are
not as “complete” (i.e., they do not contain the wide variety
of nutrients) as enteral formulas or an oral diet because of
the complexity of adding all the nutrients found in nature to
an intravenous solution.
ENTERAL TUBE FEEDING IN
CLINICAL NUTRITION
deliver nutrients orally. The patient can be given small, fre-
quent, nutrient-dense meals with an oral liquid nutritional
supplement. If oral intake remains suboptimal despite
attempts to increase nutrient intake with nutritional supple-
ments and diet changes, then enteral tube feeding can be
initiated to meet nutrient and energy requirements. If it is
not feasible to use the GI tract for feeding or if the GI tract
cannot effectively provide consistent and adequate nutrition,
then PN may be an appropriate feeding modality. Therefore
the following questions must be answered:
• Does the patient require nutrition support?
• What is the optimal route of feeding: oral, tube feeding,
or parenteral?
• Will the enteral route alone be sufficient to meet nutrient
and energy requirements?
• What type of formula is needed, and how should it be
provided?
• Does the patient require long-term nutrition support?

Modes of Enteral Nutrition Support Oral Diet

Many patients with a functioning GI tract do not or cannot When a patient does not consume a nutritionally complete
eat a sufficient amount of nutrients by mouth to restore, diet, the energy value of foods in the oral diet can be increased
repair, or maintain physiologic systems or body tissues. The according to patient tolerance and preference with added
first option for providing adequate nutrition should be to sauces, seasonings, and dressings. Frequent, less bulky,
426 PART 3â•… Introduction to Clinical Nutrition
EVIDENCE-BASED PRACTICE
Probiotics
The popularity of probiotics has increased greatly in recent
years, but the truth is that probiotics have been the subject of
research for some time now. In fact, probiotics have been
researched so often that a joint effort by the Food and Agricul-
ture Organization of the United Nations (FAO) and World Health
Organization (WHO) established guidelines for the evaluation
of probiotics in food in October 2001.1
Probiotics have been defined as “live microorganisms that,
when administered in adequate amounts, confer a health
benefit on the host.”1 Some of the confirmed positive conse-
quences of ingested probiotics include enhanced lactose diges-
tion for individuals with lactose intolerance, reduced incidence
of sepsis, and enhanced hepatic function for patients with
alcohol-related or hepatitis C–related cirrhosis to name just a
few.1,3 The negative side effects of probiotic ingestion are, at
best, rare and limited to individuals with underlying medical
conditions.1
Intestinal microflora survive by consuming very small amounts
of indigestible food that people eat. The waste products of
the microflora can be beneficial, including the production of
vitamin K and medium-chain fatty acids, which the host can
use.4 During periods of fasting, or when the diet does not
supply sufficient nutrition for the microflora, they decrease in
number.
Periods of fasting and decreased gastric motility are often
found hand in hand with patients on PN or EN. Decreased
gastric motility is a common and serious problem in critically ill
patients as well. The decreased motility can affect EN efforts,
resulting in atrophy of intestinal mucosa, sepsis, and multiple
organ failure. Although probiotics have not been found to effec-
tively reverse the effects of inhibited gastric motility, they have
been proven effective in managing all forms of diarrhea. To
understand the importance of effectively managing diarrhea,
see the Case Study box at the end of this chapter.
Because of the nature of numerous procedures performed in
hospitals, many patients are, at least in the short term, left in
a fasting state for the purpose of surgical preparation, as well
as for other reasons. Probiotics have been shown to have
beneficial effects on patients during fasting periods, and
concentrated small meals may be helpful so that the patient
is not overwhelmed or discouraged by a tray full of food. If
a patient is on a modified diet (e.g., a low-fat, low-sodium,
or diabetic diet), then liberalization of the diet as much as is
medically feasible can help improve oral intake. For example,
changing from a regimented 1800-kcal diabetic diet to a
carbohydrate-counting diet allows the patient more flexibil-
ity in food selection. In some cases it may be necessary to
liberalize to an unrestricted or regular diet to increase oral
intake. Depending on the patient’s condition and food prefer-
ences, an oral liquid nutritional supplement, commercially
available or made in-house, can be provided with or between
meals. However, taste fatigue can happen fairly rapidly
when patients are receiving two to six cans of an
administration of probiotics can help maintain nutritional status,
including enhanced recovery from malnutrition and reduced
mucosal atrophy, at least in animal models.2
However, probiotics may have little clinical significance in
critically ill patients. In one study the probiotic Lactobacillus
plantarum 299v was enterally fed to critically ill patients.4 A
significantly delayed attenuation of systemic inflammatory
response (SIRS) was found in the treatment group versus
the probiotic group, although the design of the study could
not confirm this delayed attenuation was caused by the
probiotics.
The end result of the study concluded that probiotics may
play a hand in delaying SIRS but could not reduce morbidity or
mortality in critically ill patients.
In the end, consumer acceptance and researcher curiosity is
spurring the demand for more research into the beneficial
effects of probiotics. Probiotics are being studied at an increas-
ing rate, and research is showing promising results; however,
not enough consistent information is available to make a pro-
fessional recommendation to use probiotics in the treatment
of patients on EN or PN. Perhaps with more time, probiotics
may find a place in assisting those on EN or PN, but for now,
we will simply have to accept that probiotics only have a place
in the intestines of the healthy.
References
1. FAO/WHO guidelines for the evaluation of probiotics in food.
Joint FAO/WHO Working Group report on drafting guidelines
for the evaluation of probiotics in food, London, Ontario,
2002, pp 1–11.
2. Dock DB, Latorraca MQ, Aguilar-Nacimento JE, et╯al: Probi-
otics enhance recovery from malnutrition and lessen colonic
mucosal atrophy after short-term fasting in rats. Nutrition
20:473, 2004.
3. O’Brien A, Williams R: Nutrition in end-stage liver disease:
principles and practice. Gastroenterology 134:1729, 2008.
4. McNaught CE, Woodcock NP, Anderson AD, et╯al: A pro-
spective randomized trial of probiotics in critically ill patients.
Am J Clin Nutr 24:211, 2005.
oral nutritional supplement per day. Patients may use their
nutritional supplements as meal replacements, therefore not
increasing overall energy and nutrient intake. It is important
to offer nutritional supplements in a variety of flavors and
textures to maintain adequate consumption. Some facilities,
particularly those specializing in long-term care, have found
that dispensing oral nutritional supplements in small amounts
of 30 to 60╯mL during times when medications are adminis-
tered improved oral nutritional supplement intake and nutri-
ent delivery.30,31
Enteral Tube Feeding
If a sufficient oral intake of nutrients and energy is not pos-
sible, then the next option is EN by tube feeding, either as a
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition
supplement to oral dietary intake or as the sole source of
nutrition.
Indications for Enteral Tube Feeding
A.S.P.E.N. has published guidelines for indications for nutri-
tion support.7 Enteral tube feeding is indicated for patients
who are (or who are likely to become) malnourished and
unable or unwilling to consume adequate nutrition by mouth.
Factors that affect the decision to provide enteral tube
feeding include the patient’s preadmission nutritional status,
risk for malnutrition based on current disease or condition,
ability to consume a nutritionally complete oral diet, and
functional status of the GI tract. Research found no benefit
to aggressive early enteral tube feeding for patients who were
not malnourished versus those who waited 6 days to begin
an oral diet.32
╇ COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)
Homemade Enteral Formulas: A Recipe for Trouble?
Home-based enteral nutrition (EN) support is a common and
safe practice that has been in existence for decades. Many
people have benefited from the freedom and medical support
it provides, and they can maintain a healthy nutritional status
in spite of the fact they cannot consume an oral diet. Advance-
ments in pumps, tubes, and placement of tubes are all contrib-
uting factors to the success rate of home tube feeding, but
another major improvement of note is the development of
enteral feeding solutions. Over the years, commercial enteral
feeding solutions have grown to encompass many brands and
formulas specialized for nutrient needs or even a particular
disease state. Most formulas can supply total nutrition to the
recipient of EN support and cause few side effects if adminis-
tered and calculated correctly. Therefore with all of the options
commercially available, why would someone want to make
“homemade” enteral solutions? More importantly, is it safe to
do so?
In the past, homemade enteral solutions were a widely used
and accepted entity for EN support at home and even in hos-
pitals. Many individuals considered homemade solutions a
more economical and personally fulfilling feeding method.
Home caretakers such as mothers, fathers, or spouses believed
making the solutions was a more affectionate and devoted
method as opposed to simply opening a can. Even so, current
consensus directs the consumer away from these homemade
solutions, not only because of the advancements in commer-
cial formulas but also because of potential problems with
homemade solutions.
As mentioned previously, commercial formulas are nutrition-
ally complete and specialized for a wide array of nutritional and
disease states. These commercial feedings are also consistent
in their formulation and, as such, are easily quantifiable to
readily meet the recipient’s needs. Conversely, homemade
solutions of varying composition have no exact method of
quantification or verification of their nutritional content. Further-
more, these solutions are not tested for digestive and absorp-
tive properties as commercial solutions are, which can lead to
a host of problems such as dehydration, constipation, vitamin
deficiency, and even severe malnourishment.
427
ENTERAL TUBE FEEDING FORMULAS
Complete Enteral Tube Feeding Formulas
Blenderized Formulas
Prior to the availability of commercial enteral formulas, the
first enteral formulas were created by blenderizing regular
diets and using broth or gravy to thin the mixture enough to
flow through feeding tubes. Today the majority of enteral
tube feedings in health care facilities are given with a defined,
commercially prepared enteral tube feeding formula.
However, financial or personal reasons may motivate a patient
or family to use blenderized formulas for home enteral tube
feeding. Although emotional comfort may be achieved by
using home-prepared food, its use does create problems (see
the Complementary and Alternative Medicine [CAM] box,
“Homemade Enteral Formulas: A Recipe for Trouble?”).
Sanitation is a critical variable to consider when dealing
with nutrition support and choosing an enteral feeding solution.
Its importance cannot be overstated. Although no way exists
to totally avoid contamination of enteral feeding, the use of
commercially prepared solutions can considerably limit the
chance of a health risk. Points of potential contamination
such as preparation, cooking, and blenderizing are all omitted,
leaving the caretaker with less of a chance of exposing the
recipient to a potentially serious bacterial or viral infection;
this can be especially important for those who have an
altered immune system. In addition, commercially available
formulas lessen the workload of the administer and guard
the recipient from clogs associated with underblenderized
feedings.
For the vast majority of those receiving EN support, com-
mercially available enteral tube feeding solutions are the appro-
priate choice. Recently there has been a resurgence of use of
home blenderized enteral formulas. Caregivers who are using
home blenderized enteral formulas should be educated regard-
ing safe practices.
Bibliography
Duperret E, Trautlein J: Homemade tube feeding formula …
two dietitians’ perspective, Tucson, Ariz., November 20,
2003, Mealtime Notions, LLC. from: <http://www.mealtime
notions.com/GuestOpinions/GuestOpinion1Homemade
TubeFeedingFormula.htm>. Retrieved December 22, 2005.
Malone A: Enteral formula selection: a review of selected cat-
egories. Pract Gastroenterol 29(6):44, 2005.
Mokhalalati JK, Druyan ME, Shott SB, et╯al: Microbial, nutri-
tional and physical quality of commercial and hospital pre-
pared tube feedings in Saudi Arabia. Saudi Med J 25(3):331,
2004.
Stanley D: Forward. JPEN J Parenter Enter Nutr 25(Suppl 5):S2,
2002.
Sullivan MM, Sorreda-Esguerra P, Platon MB, et╯al: Nutritional
analysis of blenderized enteral diets in the Philippines. Asia
Pac J Clin Nutr 13(4):385, 2004.
428 PART 3â•… Introduction to Clinical Nutrition
These problems involve its physical form, which could cause
tube clogging, an increased risk of bacterial contamination,
and inconsistent nutrient adequacy based on the foods chosen
and preparation techniques used. The blenderized formula
must be given into the stomach and requires a normal GI
tract to digest and absorb the nutrients contained in the
formula. Use of blenderized formulas has decreased over the
past 20 years with the proliferation of commercially available
enteral tube feeding formulas.
Commercial Enteral Tube Feeding Formulas
In contrast to homemade enteral formulas, commercial
enteral tube feeding formulas provide sterile, nutritionally
complete, homogenized solutions suitable for small-bore
enteral feeding tubes. Enteral tube feeding formulas are avail-
able as polymeric, semielemental or oligomeric, and elemen-
tal or monomeric formulas (Table 19-2).33 It is important to
keep abreast of products currently available because new for-
mulations and enteral tube feeding products are constantly
being developed. Polymeric enteral tube feeding formulas
require digestion and are available with and without fiber.
Macronutrients and micronutrients of a polymeric tube
feeding formula can be modified for specific needs of patients
with various disease states. Semielemental or oligomeric tube
feeding formulas are partially digested or hydrolyzed. Smaller
molecules increase the osmolality of the formula. Elemental
or monomeric tube feeding formulas are completely predi-
gested and require only absorption for assimilation into the
body. These formulas have the highest osmolality, lowest vis-
cosity, and worst taste of all enteral tube feeding formulas.
Enteral tube feeding formulas will also vary according to
nutrient density from 1 to 2╯kcal/mL. More concentrated for-
mulas are designed for patients with fluid intolerance, such
as those with renal, hepatic, or cardiac failure, as well as for
patients who desire less volume or fewer feedings per day.
However, if patients who receive a concentrated enteral tube
feeding formula do not have fluid restrictions, it is imperative
to provide adequate water so that they do not become
dehydrated.
Nutrient Components
Carbohydrates
Approximately 50% to 60% of the energy in the American
diet comes from carbohydrates, starches, and sugars. Carbo-
hydrates are the body’s primary energy source (see Chapter
3). Although large starch molecules are well tolerated and
easily digested by most patients, their relative insolubility
creates problems in enteral tube feeding formulas. Thus
smaller sugars formed by partial or complete breakdown of
cornstarch and other glucose polymers are common tube
feeding formula components (see Table 19-2).33 Very few
enteral tube feeding formulas contain lactose, because lactose
intolerance is common among hospitalized patients. Tube
feeding formulas can also contain soluble and insoluble
fiber. Considerable controversy exists as to the benefit of pro-
viding fiber in enteral tube feeding formulations.26,33 Insolu-
ble fiber increases stool volume and thus is used to treat
problems with gastric motility such as constipation or diar-
rhea. Soluble fiber has been promoted to improve blood
sugar control, reduce serum cholesterol levels, and maintain
colon health. The focus on maintaining normal intestinal
bacteria has resulted in increased research and availability
of prebiotics and probiotics given with or in enteral tube
feeding formulas. Prebiotics, nondigestible food components,
provide fuel to enhance repletion of normal bacteria found
in the GI tract, whereas probiotics, live nonpathogenic
microbes, are designed to repopulate by providing “good”
bacteria directly to the GI tract.34 The strain of probiotic and
combination of strains most effective depends on the thera-
peutic intent (see Evidence-Based Practice box, “Probiotics”
for more information).
Protein
Protein content of standard enteral tube feeding formulas is
designed to maintain body cell mass and promote tissue syn-
thesis and repair (see Chapter 5). Biologic quality of dietary
protein depends on its amino acid profile, especially its rela-
tive proportions of essential amino acids. To supply these
needs, the following three major forms of protein are used in
nutrition support enteral tube feeding formulas: (1) intact
proteins, (2) hydrolyzed proteins, and (3) crystalline amino
acids (see Table 19-2).33
1. Intact proteins: Intact proteins are the complete and
original forms as found in foods, although protein isolates
such as lactalbumin and casein from milk are intact pro-
teins that have been separated from their original food
source. These larger polypeptides and proteins must
be broken down further (digested) before they can be
absorbed.
2. Hydrolyzed proteins: Hydrolyzed proteins are protein
sources that have been broken down by enzymes into
smaller protein fragments and amino acids. These smaller
products—tripeptides, dipeptides, and free amino acids—
are absorbed more readily into the blood circulation.
3. Crystalline amino acids: Pure crystalline amino acids are
readily absorbed, particularly when combined in a mix of
dipeptides and tripeptides. The small size of the amino
acid results in an increase in osmolality of the formula.
Amino acids result in a bitter-tasting formula. If an ele-
mental tube feeding formula is used as an oral supple-
ment, then it requires flavoring aids or special preparation
methods to improve taste (e.g., pudding, frozen slush,
Popsicle). However, despite flavorings, the taste can still be
unacceptable to a sick patient or can quickly lead to taste
fatigue and refusal by the patient.
KEY TERM
osmolalityâ•… The ability of a solution to create osmotic pres-
sure and determine the movement of water between fluid
compartments; determined by the number of osmotically
active particles per kilogram of solvent; serum osmolality is
280 to 300╯mOsm/kg.
 TABLE 19-2 CATEGORIES AND MACRONUTRIENT SOURCES FOR VARIOUS TYPES OF ENTERNAL FORMULAS
TYPE OF CARBOHYDRATE PROTEIN NONPROTEIN CALORIE-
FORMULA PROTEIN SOURCES SOURCES FAT SOURCES kcal/mL CONTENT TO-NITROGEN RATIO EXAMPLES
Intact (Polymeric)
Calcium and magnesium Maltodextrin Medium-chain 1-2 30-84╯g/L 75-177╛:╛1 Boost (No)
caseinates Corn syrup solids triglycerides Compleat (No)
Sodium and calcium Sucrose Canola oil Fibersource (No)
caseinates Cornstarch Corn oil Isocal (No)
Soy protein isolate Glucose polymers Lecithin Isosource (No)
Calcium potassium Sugar Soybean oil Jevity (R)
caseinate Vegetables Partially hydrogenated Nutren (Ne)
Delactosed lactalbumin Fruits soybean oil Osmolite (R)
Egg white solids Nonfat milk High-oleic safflower oil Resource (No)
Beef Beef fat TwoCal HN (R)
Nonfat milk Ultracal (No)

Hydrolyzed (Oligomeric or Monomeric)

Enzymatically hydrolyzed Hydrolyzed cornstarch Medium-chain 1-1.33 21-52.5╯g/L 67-282╛:╛1 Advera (R)
whey or casein Sucrose triglycerides AlitraQ (R)
Soybean or lactalbumin Fructose Sunflower oil Criticare HN (No)
hydrolysate Maltodextrin Lecithin Crucial (Ne)
Whey protein Tapioca starch Soybean oil Peptamen (Ne)
Soy protein hydrolysate Glucose Safflower oil Perative (R)
oligosaccharides Corn oil Tolerex (No)
Coconut oil Vital HN (R)
Canola oil Vivonex Plus
Sardine oil (No)

Modular
Protein Low-lactose whey and — — Per 100╯g Per 100╯g — Casec (No)
casein 370-424 75-88.5 ProMod (R)
Calcium caseinate Resource Protein
Free amino acids Powder (No)
Carbohydrate — Maltodextrin — Per 100╯g — — Moducal (No)
Hydrolyzed cornstarch 380-386
Fat — — Safflower oil Per 1╯tbsp — — MCT Oil (No)
Polyglycerol esters of 67.5-115 Microlipid (No)
fatty acids
Soybean oil
Lecithin
Medium-chain
CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition

triglycerides
Fish oil

Modified from Gottschlich MM, Shronts EP, Hutchins AM: Defined formula diets. In Rombeau JL, Rolandelli RH, editors: Clinical nutrition: enteral and tube feeding, ed 3, Philadelphia, Pa.,
1997, Saunders.
429

Ne, Nestle; No, Novartis; R, Ross.

430 PART 3â•… Introduction to Clinical Nutrition
Fat
The major roles of fat in an enteral tube feeding formula are
to supply a concentrated energy source, essential fatty acids,
and a transport mechanism for fat-soluble vitamins. Major
forms of fat used in standard formulas are butterfat in milk-
based mixtures; vegetable oils from corn, soy, safflowers, or
sunflowers; medium-chain triglycerides (MCTs); and lecithin
(see Table 19-2).33 Vegetable oils supply a rich source of the
essential fatty acids—linoleic and linolenic acids. Researchers
continue to examine outcomes related to enteral tube feeding
formulas containing various combinations of short-chain
fatty acids, medium-chain fatty acids, and omega-3 fatty
acids (see Chapter 4).35,36
Vitamins and Minerals
Standard whole-diet commercial tube feeding formulas
provide 100% of the Recommended Dietary Allowance
(RDA) and Dietary Reference Intake (DRI) for vitamins and
minerals when the formula is provided at a specific volume
per day. The volume required to provide the RDA-DRI varies
with each tube feeding formula and the nutrient require-
ments of the patient. Delivery of a reduced volume and use
of diluted formulas may require supplementation with
vitamin and mineral preparations. Patients with nutrient
deficiencies may require supplementation of specific vita-
mins and minerals in addition to the standard vitamin and
mineral composition of the enteral tube feeding formula.
Several enteral tube feeding formulas are designed for specific
patient populations and contain micronutrients designed to
meet the requirements of the particular disease state or
condition.
Physical Properties
After selecting a tube feeding formula according to the
patient’s nutritional requirements and GI function, the clini-
cian must consider physical properties of the formula that
can affect tolerance. Individual intolerance is reflected in
delayed gastric emptying, abdominal distention, cramping
and pain, diarrhea, or constipation. A factor often evaluated
when a patient demonstrates intolerance is osmolality of the
enteral tube feeding formula. Osmolality is based on concen-
tration of the formula and defined as number of osmotic
particles per kilogram of solvent (water), energy-nutrient
density, and residue content. However, no evidence indicates
that enteral tube feeding formula osmolality is the primary
contributor to formula intolerance. Enteral tube feeding for-
mulas can approximate 700╯mOsm, whereas some medica-
tions are 4000╯mOsm or more. Signs and symptoms of enteral
tube feeding intolerance, of which diarrhea is the most
common, are more often related to inappropriate tube feeding
techniques or drug interactions.
Medical Foods for Special Needs
Certain tube feeding formulas designed for special nutrition
therapy are called medical foods. The U.S. Food and Drug
Administration (FDA) first recognized the concept of medical
foods as distinct from drugs in 1972, when the first special
formula was developed for treatment of the genetic disease
phenylketonuria (PKU) in newborns (see Chapter 12). The
definition of medical foods remained rather murky as medical
research developed an increasing number of special formulas.
The Orphan Drug Act has defined medical food as a food that
is formulated to be consumed or administered enterally
under the supervision of a physician and that is intended for
the specific dietary management of a disease or condition for
which distinctive nutritional requirements, based on recog-
nized scientific principles, are established by medical evalua-
tion. The Orphan Drug Act was subsequently incorporated
into the reformed Nutrition Labeling and Education Act
of 1990.
An explosion of specialty enteral tube feeding formulas
has occurred over the past 10 years. Several products are
available in each category of disease- or condition-specific
formulation: (1) end-stage renal disease, (2) hepatic disease,
(3) pulmonary disease, (4) diabetes mellitus, (5) malabsorp-
tion syndromes, (6) immunoincompetence, (7) oncology,
and (8) metabolic stress. Every patient with one of the previ-
ous diagnoses does not need a specialty tube feeding formula.
Indications for specialty tube feeding formulas are limited to
a small subset of patients within each disease state classifica-
tion for which a specialty formula is designed. Considerable
debate exists regarding the treatment value and cost-
effectiveness of specialty tube feeding formulas; therefore
scientific evidence to support their use is needed before use
can be recommended.26
Modular Enteral Tube Feeding Formulas
Commercially available, nutritionally complete enteral
formula products for tube feeding are designed with a fixed
ratio of nutrients to meet general standards for nutritional
needs. However, some patients’ particular needs are not met
by these standard fixed-ratio tube feeding formulas, and they
require an individualized modular formula. An individual
formula, composed completely of modular components, is
planned, calculated, prepared, and administered with the
expertise of the RD. Modular enteral components are listed
in Table 19-2. However, the more common use of modular
components is the addition of carbohydrate, fat, or protein
to a commercial formula to individualize the calorie and
protein content of the formula for the patient. For example,
additional protein powder can be added to increase the
amount of protein per liter, or more carbohydrate or fat can
be added to increase energy concentration. Other modular
nutrients such as fiber and probiotics or prebiotics can also
be added to the feeding regimen but should be given sepa-
rately through the feeding tube and not added directly to the
KEY TERM
medical foodsâ•… Specially formulated nutrient mixtures for
use under medical supervision to treat various metabolic
diseases.
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition
commercial tube feeding formulation. Every component
added to an enteral tube feeding formula can increase the
osmolality and viscosity of the formula and contribute to
feeding intolerance, bacterial contamination, or clogging of
the feeding tube.
Blue food dye is often added to tube feeding formulas to
detect aspiration of formula into the trachea and lungs.
Concern exists as to safety, specificity, and sensitivity of blue
dye in identifying aspiration in tube-fed patients.38-40 The
addition of blue food dye increases risk of bacterial contami-
nation, false-positive occult stool test, discoloration of the
skin and body fluids, and death. In addition, no standardiza-
tion exists for how much food dye to add per liter of tube
feeding formula, with formula hues ranging from pale to
cobalt blue. Methylene blue should not be added to tube
feeding formulas because it can adversely affect cellular func-
tion.41 Colored dyes are not diagnostic for aspiration, are
potentially harmful, and should not be added to tube feed-
ings.40 Nonrecumbent positioning (elevating the head of the
bed 30 to 40 degrees) is an evidence-based method for aspira-
tion prevention and should be emphasized in all tube-fed
patients.40
ENTERAL TUBE FEEDING DELIVERY SYSTEMS
Tube Feeding Equipment
Nasoenteric Feeding Tubes
Small-bore nasoenteric feeding tubes, generally from 8 to 12
French, made of softer, more flexible polyurethane and sili-
cone materials have replaced former large-bore stiff tubing.
Small-bore feeding tubes are more comfortable for patients
and permit the infusion of commercially available enteral
tube feeding formulas. Nasoenteric tubes can be inserted into
either the stomach or beyond the pyloric valve into the small
intestine. (Figure 19-2).42 Distal placement of a feeding tube
beyond the ligament of Treitz into the jejunum is often
Nasogastric
Nasoduodenal
Nasojejunal
Nonsurgical
feeding routes
FIGURE 19-2╇ Types of enteral feeding routes. (From Rolin Graphics in Grodner M, Anderson
SL, DeYoung S: Foundations and clinical applications of nutrition: a nursing approach, ed 2,
St Louis, Mo., 2000, Mosby.)
431
preferred for patients with a history or risk of aspiration,
impaired gastric emptying, depressed gag reflex, neurologic
impairment, and critical illness.27 Feeding tube insertion can
be done blindly at the bedside or using radiographic visual-
ization. Placement of a feeding tube should be performed by
experienced, trained personnel. Feeding tube placement is an
invasive procedure and carries the risk of misplacement into
the lungs or brain, as well as perforation of the GI tract.
During placement, aspirates of GI contents can be checked
for pH and enzyme concentration, as well as visually inspected
to reduce the number of radiographs required to determine
when the desired location has been reached.43 However, no
tube feeding should be infused until feeding tube placement
is confirmed by radiography.
Tube Feeding Enterostomies
Nasoenteric tube placement is usually indicated for short-
term therapy. However, for enteral feeding anticipated to last
more than 3 to 4 weeks, surgically or endoscopically placed
enterostomies are preferred42 (see Figure 19-2), as follows:
• Esophagostomy: A cervical esophagostomy can be placed at
the level of the cervical spine to the side of the neck after
head and neck surgeries for cancer or traumatic injury.
This removes the discomfort of a nasoenteric tube, and the
entry point can be concealed under clothing.
• Gastrostomy: A gastrostomy tube is surgically or endo-
scopically placed in the stomach if the patient is not at risk
for aspiration and has normal gastric motility.
• Jejunostomy: A jejunostomy tube is surgically or endo-
scopically placed past the ligament of Treitz in the jejunum,
the middle section of the small intestine. This procedure
is indicated for patients with neurologic impairment, a
risk or history of aspiration, an incompetent gag reflex, or
gastric dysfunction. Gastric dysfunction can be related to
gastric atony, gastroparesis, gastric cancer, gastric outlet
obstruction, or gastric ulcerative disease.
Esophagostomy
Gastrostomy/
percutaneous
endoscopic
gastrostomy
Jejunostomy/
percutaneous
endoscopic
jejunostomy
Surgically placed
feeding routes
432 PART 3â•… Introduction to Clinical Nutrition
Care and Maintenance of Enteral Feeding Tubes
Enteral feeding tubes should be flushed routinely with water
to maintain patency and prevent clogging. Tap water is gener-
ally sufficient. If concern exists regarding safety of the water
source or if the patient is immunosuppressed, then sterile
water may be used to flush the feeding tube. Standard flush-
ing volumes are 30╯mL of water every 4 hours during con-
tinuous feedings. Water flushes for intermittent and bolus
enteral feedings are a minimum of 30╯mL immediately after
each feeding. The amount of water flushed through the tube
is adjusted according to the patient’s fluid requirements and
tolerance. Larger fluid volumes will be needed for patients
who cannot drink water for hydration; smaller fluid volumes
are needed for patients on fluid restrictions.
General Comfort Tips for Patients with
Nasoenteric Tube Feedings
• Thirst, oral dryness: Lubricate lips, chew sugarless gum,
brush teeth, rinse mouth frequently with water, and suck
lemon drops occasionally. If a small amount of water by
mouth is permitted, then let ice cubes melt in the mouth
to soothe mouth and esophagus.
• Tube discomfort: Gargle with a mixture of warm water and
mouthwash, gently blow the nose, and clean the tube regu-
larly with water-soluble lubricant. If discomfort persists,
then pull the tube out gently, clean it, and reinsert a new
tube. (Many long-term users of tube feeding have learned
to pass their own nasogastric tubes.)
• Tension, fullness: Relax and breathe deeply after each tube
feeding infusion.
• Loud stomach noises: Take feedings in private.
• Limited mobility: Change positions in bed or chair, and
walk around the house or hospital corridor. Perform
range-of-motion exercises while confined to bed.
• General gustatory distress with feeding: Warm or chill the
tube feeding formula, but avoid making the formula too
cold because that increases risk of diarrhea.
• Persistent hunger: Chew a favorite food, then spit it out;
chew gum; or suck lemon drops.
• Inability to drink: Rinse the mouth frequently with water
or other liquids.
Ideally no medications should be put down small-bore
feeding tubes because medications are a primary contributor
to feeding tube clogs. However, the reality of life often requires
administration of medications via feeding tubes. Flush with
30╯mL of water before and after medication administration.
Each medication should be administered separately with
5╯mL of water flushed through the tube between each medi-
cation. Check with a pharmacist when determining which
medications are compatible with administration through a
feeding tube (see the Diet-Medications Interactions box,
“Drug-Nutrient Interactions”). Medications should never
be added directly to the tube feeding formula because of the
risk of drug-nutrient interactions. Warm water, a 30- to
60-mL syringe, and a pumping action can be used to dislodge
a clog within the feeding tube. No evidence supports the use
of other liquids such as soft drinks or juices to declog feeding
tubes.44 A pancreatic enzyme and bicarbonate mixture may
be effective against formula clogs but will not dissolve medi-
cation clogs.45
Tube Feeding Containers and Pumps
The enteric tube feeding system includes the formula con-
tainer, connection tubing, and often an infusion pump. A
variety of tube feeding containers and feeding sets is available.
Tube feeding formulas can be administered by syringe, gravity
drip, or a volumetric pump. A pump may be needed for more
accurate control, which is essential for tube feedings given
directly into the small intestine, tube feedings infused at slow
rates, and tube feedings using more viscous formulas. Criti-
cally ill patients should also be tube fed by volumetric pump
to increase tolerance to EN support.
Tube feeding delivery systems are categorized as either
open or closed. An open delivery system involves pouring a
volume of formula from a can or mixing bowl (or container)
into an empty tube feeding bag, syringe, or infusion con-
tainer. The infusion bag or container is reopened and refilled
periodically with more formula. Clean technique is required
when decanting the tube feeding formula into the bag and
when handling the tubing connections. Formula hang time is
limited to 8 hours or less.24,46 Hang time is further reduced if
additives such as protein powder are placed into the formula.
The tube feeding infusion bag should be rinsed with sterile
water before initial filling and subsequent refilling with
formula.24 The tube feeding administration set, tubing and
infusion bag, should be changed every 24 hours. The primary
benefit of the open system is the ability to modulate the tube
feeding formula.
The closed system is composed of a sterile vessel that is
purchased prefilled with tube feeding formula. The container
is spiked and connected to an infusion pump. Hang time is
expanded to 24 to 48 hours (refer to manufacturer’s guide-
lines for hang time of product being used). Benefits of the
closed system are a reduction of time, labor, and contamina-
tion risk.47,48 Caveats of the closed system are its increased cost
and the inability to modulate the formula. Regardless of the
system used, good hand washing is essential to reduce bacte-
rial contamination. Clinicians working with patients on tube
feedings need to be familiar with different delivery systems,
types of enteral feeding tubes, and features of enteral feeding
pumps to determine which products are preferable for their
facility and patient population.
Infusion of Enteral Tube Feeding
Tube feedings can be provided via bolus, intermittent, or
continuous infusion through a feeding tube. Patients can
progress from one infusion modality to another as their
KEY TERM
viscousâ•… Physical property of a substance dependent on the
friction of its component molecules as they slide by one
another; viscosity.
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition 433

╇ DIET-MEDICATIONS INTERACTIONS

Drug-Nutrient Interactions
Even though enteral nutrition (EN) support is becoming rather
ordinary, relatively few clinical studies are available that
document drug-nutrient interactions associated with enteral
feeding solutions. This relates to the fact that administration
of drugs through a feeding tube should be considered a
last resort, but it can also be linked to the theory that
interactions are so common and varied they are simply not
reported. However, potential consequences of interactions
should not be taken lightly. Use of EN support poses many
pharmaceutic and dietary complications that can physically
interfere with administration of nutrition, alter the bioavailability
of a given drug, or cause long-term vitamin and mineral
deficiencies.
Physical interferences with nutrition support are problems
related to manipulation of the delivery system of nutrition
support or the drug before it enters the body. Physical interfer-
ences are the most commonly reported problems and include
but are not limited to occlusion of the feeding tube related to
medication administration, manipulation of solid-dose forms of
drugs, and exposure of photosensitive drugs to light for
extended periods of time. No medication is formulated to be
administered in combination with EN support; therefore the
composition can sometimes alter viscosity of enteral feeding
solutions and cause occlusion of the feeding tube. Further-
more, when crushing a solid-dose pill for administration through
a feeding tube, there is a risk of occlusion, and the bioavail-
ability of the medication and its time release properties will be
altered considerably. Any type of drug added to a feeding solu-
tion will have longer exposure to ultraviolet light than if taken
orally, which in some cases can compromise therapeutic
effects.
The recipient of EN support is able to obtain total nutrition
from his or her enteral feeding solutions; however, composi-
tion of these enteral feeds differ considerably from orally fed
diets. Enteral feeds contain increased concentrations of pro-
teins, vitamins, and minerals, which can bind drugs or alter the
mechanism by which they are metabolized. Closely related, but
resulting in a more long-term effect, are vitamin and mineral
binding. Chronic problems such as osteoporosis can develop
over time as a result of an interaction that goes unnoticed. The
following is a brief list of some classically noted drug-nutrient
interactions related to EN support.

Drug Interaction Possible Remedy

Phenytoin Probable cause of interaction is the binding of phenytoin to
caseinate proteins found in enteral feeds, preventing its
absorption from the gastrointestinal (GI) tract.
Quinolones Concurrent administration of a quinolone and enteral feed
could compromise antimicrobial efficiency. This is
related to the divalent cations found in enteral nutrition
(EN) formulas.
Warfarin Decreased bioavailability of this drug results from high
binding of warfarin to proteins found in EN. In addition,
vitamin K was formerly found to reverse anticoagulant
effects of warfarin, but most current enteral feeds
contain little or no vitamin K.
Withhold feedings for 2 hours after administration
of phenytoin. Increased dose might be in order.
Withhold feedings 1 hour before and 1 hour after
administration of quinolones. Increase dose
when converting from intravenous to oral form.
Avoid concurrent administration of warfarin and
EN solutions. Choose EN supplements that
contain limited vitamin K content.

Working as a team with physicians, nurses, speech patholo-
gists, and pharmacists can substantially reduce interactions
stemming from EN support. By educating those who adminis-
ter and prescribe medications, risks involved can be controlled
and monitored correctly.
Bibliography
A.S.P.E.N. Board of Directors: Section IX: drug nutrient interac-
tions. JPEN J Parenter Enter Nutr 26:1, 2002.
British Association for Parenteral and Enteral Nutrition, The
British Pharmaceutical Nutrition Group: Drug administration
via enteral feeding tubes: a guide for general practitioners
and community pharmacists, Redditch, UK, 2001, BAPEN.
Finch C, Self T: Medication and enteral tube feedings: clinically
significant interactions. J Crit Illn 16:20–21, 2001.
Fitzgerald M: What do I need to know about drug interactions
with enteral feeding? Medscape Nurses 7:1, 2005. from:
<http://www.medscape.com/viewarticle/498270>. Retrieved
July 1, 2010.

medical condition changes. All enteral tube feedings should
be initiated at full strength. Tolerance to tube feeding has not
been shown to be improved with dilution of the formula.49
Enteral tube feedings should be introduced gradually and
progressed per patient tolerance. Gastric tube feedings can be
given as bolus, intermittent, or continuous feedings. Small
bowel tube feedings are given as continuous feedings.
Bolus tube feeding is generally initiated with 120 to
240╯mL of formula every 3 to 4 hours and increased by 60 to
240╯mL every 8 to 12 hours, depending on the level of illness
and tolerance. The infusion period is relatively short, 10 to
20 minutes, and is infused through a syringe or from a bag
by the flow of gravity.50 The infusion should not exceed 40 to
60╯mL/min. Gravity infusion is controlled by a roller clamp,
434 PART 3â•… Introduction to Clinical Nutrition
raising or lowering the formula container, or advancing the
plunger into the syringe.
Intermittent tube feedings are similar to bolus feedings
but are given over a longer time period of 30 to 60 minutes
every 3 to 6 hours. The enteral tube feeding formula is placed
in a bag with rate controlled by a roller clamp. This method
is used to provide periodic gastric feedings to patients who
do not tolerate the more rapid infusion of a bolus feeding.
The maximum amount of formula given by bolus or inter-
mittent feedings varies from 240 to 500╯mL per feeding and
is based on patient tolerance and requirements.
Continuous tube feedings are provided over a defined
period, with the formula infused by gravity or pump. Con-
tinuous feedings can be given over 24 hours or cycled over a
shorter period, such as 8 to 20 hours per day. Enteral tube
feeding tolerance is generally better in critically ill patients
who are fed continuously regardless of whether fed into the
stomach or small bowel.
All patients fed through a feeding tube should have the
head of the bed elevated 30 to 45 degrees to reduce the risk
of aspiration.51 Patients fed with a tube into the small bowel
can still aspirate gastric contents and may require concomi-
tant gastric decompression during small bowel feeding.52
Patients who must lie flat or in Trendelenburg’s position
should have enteral feedings stopped.
MONITORING THE TUBE-FED PATIENT
Monitoring of the tube-fed patient should focus on transi-
tioning to an oral diet and reducing or eliminating depen-
dency on tube feeding. All patients being nourished by tube
feeding should be carefully monitored for signs and symp-
toms of enteral tube feeding intolerance. Tolerance to enteral
tube feeding is determined by GI signs of vomiting, abdomi-
nal distention or bloating, and frequency and consistency of
bowel movements. If problems occur, then the tube feeding
formula may need to be replaced, the infusion rate adjusted,
or the method of administration changed until tolerance
improves and symptoms subside. In most instances the tube
feeding formula itself is not the causative agent for the intol-
erance. Residual volume and diarrhea are two parameters that
are often used to determine tolerance to tube feeding. Both
are terms that have no standardized definition within each
institution, much less nationwide standard definitions.
Diarrhea is generally defined by the person cleaning it
up and can be based on volume, frequency, or consistency
of the stools (or a combination of these factors). Fourteen
definitions of diarrhea are found in the literature.53 Com-
monly used definitions are more than three stools per day or
more than 500╯mL of stool per day for 2 consecutive days.54
Each health care facility should define diarrhea and then
create an algorithm or protocol for treatment to reduce
unnecessary interruptions of enteral feeding.54 The most
common cause of diarrhea in the tube-fed patient is medica-
tions, primarily antibiotics and medications containing sor-
bitol (see the Health Promotion section later in this chapter
for a discussion).
The interpretation of residual volume is also often deter-
mined by caregiver experience and not evidence-based
guidelines. Enteral feeds are interrupted for gastric residual
volumes ranging from 50 to 200╯mL.55 A research study
defined acceptable residual volume as less than 200╯mL with
a nasogastric tube and less than 100╯mL with a gastrostomy
tube.56 The authors suggested high residual volumes be cor-
related with the presence of physical signs of intolerance
before stopping enteral feeding. Another study found that if
patients were given a prophylactic prokinetic agent, then a
residual volume of 250╯mL was tolerated.57 The A.S.P.E.N.
Guidelines7 and the Canadian Clinical Practice Guidelines58
state a high residual volume is more than 200╯mL for two
consecutive checks and more than 250╯mL, respectively. In
contrast, according to a survey of intensive care unit (ICU)
nurses, the nurses believed a residual volume greater than
100╯mL was excessive.59 A patient with a history of aspiration
or reflux is at risk of aspiration even with low gastric residu-
als; therefore residual volumes do not always correlate with
risk of aspiration.
GI aspirates that contain gastric enzymes and hydrochloric
acid (HCl) required for digestion, electrolytes, enteral
formula, and fluid should be returned to the patient after
determining the volume. However, if doing so would make
the patient uncomfortable or if the volume removed exceeds
300╯mL, then the residuals should be discarded and rechecked
in 1 to 2 hours. The feeding tube should be flushed with
30╯mL water after checking and returning residuals to be
sure gastric contents with digestive enzymes are no longer
within the lumen of the feeding tube. Patient tolerance of
tube feeding formula, state of hydration, and nutritional
response to tube feeding should be monitored using data
collected from a variety of sources, including laboratory,
anthropometric, physical and clinical assessment, and nursing
records. Protocols for enteral tube feeding can provide guide-
lines for troubleshooting problems and improve nutrient
delivery.60,61
Clinical and Laboratory Parameters to Monitor
Blood glucose levels should be monitored daily or more fre-
quently in patients who have diabetes or are at risk for dia-
betes. It is important not to overfeed patients on nutrition
support. Historically insulin has been provided as needed to
maintain serum glucose level at less than 200╯mg/dL. However,
a growing body of evidence indicates that glycemic control
between 110╯mg/dL62 and 140╯mg/dL63 can significantly
reduce mortality and morbidity in ICU patients.
Daily weights, compared with a baseline weight before
start of the tube feeding, along with daily input and output
measures, are essential for an accurate assessment of patient
tolerance and nutrient adequacy. Routine monitoring also
includes serum tests for potassium, sodium, chloride, carbon
dioxide (CO2), creatinine, as well as BUN and complete blood
count (CBC), along with periodic tests for urine specific
gravity. Sudden weight changes can indicate fluid imbalance
and need to be investigated. (See Box 19-2 for a list of nutri-
tion support monitoring parameters.)
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition 435

Hydration Status BOX 19-4 INDICATIONS AND

Signs of volume deficit or dehydration include weight loss, CONTRAINDICATIONS FOR
poor skin turgor, dry mucous membranes, and low blood PARENTERAL NUTRITION
pressure from decreased blood volume. Patients also demon-
Indications
strate increased serum levels of sodium, albumin, hematocrit, 1. Nonfunctional gastrointestinal (GI) tract
and BUN, as well as elevated urine specific gravity levels. a. Obstruction
Severe dehydration is critical and life threatening. Fluid b. Intractable vomiting or diarrhea
requirements can be estimated by several available formulas, c. Short-bowel syndrome
such as 1╯mL of water per kcalorie or 30 to 35╯mL/kg. Water d. Paralytic ileus
content of the enteral tube feeding formula and the amount 2. Inability to adequately use GI tract
of water given with medications and routine flushing of the a. Slow progression of enteral nutrition (EN)
feeding tube, as well as the patient’s medical condition, are b. Limited tolerance of EN
taken into consideration when determining the patient’s fluid 3. Perioperative condition
a. Severely malnourished
requirements. Fluids must be monitored for adequacy and
b. Nothing by mouth (NPO) for at least 1 week before
adjusted as necessary to attain and maintain adequate hydra-
surgery
tion. Patients with large fluid losses from fistulas, ostomies,
and drains may require intravenous hydration in conjunction Contraindications
with enteral tube feeding nutrition. 1. No central venous access
Signs of volume excess or overhydration include weight 2. Grim prognosis when parenteral nutrition (PN) will be of
gain, edema, jugular vein distention, elevated blood pressure, no benefit
and decreased serum levels of sodium, albumin, BUN, and 3. EN is an alternative means of support
hematocrit. Patients with renal, cardiac, and hepatic impair-
Conditions Previously Treated with PN that Benefit
ment may require less fluid than other patients. from Enteral Feeding
1. Inflammatory bowel disease
Documentation of the Enteral Nutrition
2. Pancreatitis
Tube Feeding
Modified from Fuhrman MP: Parenteral nutrition. Dietitian’s Edge
The patient’s medical record is an essential means of com-
2(1):53, 2001.
munication among members of the health care team. The
health care team is involved in actions and documentation
related to (1) all ongoing nutritional analyses of actual tube
feeding formula intake; (2) tolerance of the formula and any BOX 19-5 GUIDELINES FOR ORDERING
complications; (3) desired versus actual outcomes; (4) rec- PARENTERAL NUTRITION
ommendations for adjustments in tube feeding formula,
routine tube flushing, and method and rate of delivery; and 1. Determine that the patient has central intravenous access.
2. Identify amount of energy, protein, and fluid desired.
(5) education of patient and family.
3. Determine desired distribution of dextrose and lipids.
4. Indicate additives desired.
PARENTERAL FEEDING IN a. Vitamins
CLINICAL NUTRITION b. Minerals
c. Electrolytes
PN should be reserved for patients who are unable to receive d. Medications
adequate nutrition via the enteral route. A.S.P.E.N. has pub- e. Sterile water
lished general guidelines to determine when PN support is 5. Determine infusion rate based on compounded volume
appropriate.7 Indications and contraindications for PN are and time of infusion.
listed in Box 19-4.

Basic Technique
Guidelines for ordering PN are given in Box 19-5, and an
example of a basic PN solution is given in Box 19-6. PN refers
to any intravenous feeding method. Nutrients are infused
directly into the blood when the GI tract cannot or should
not be used. The following two parenteral routes are available
(Figure 19-3)64:
1. Central parenteral nutrition (CPN): A large central vein is
used to deliver concentrated solutions for nutrition
support. Osmolarity of central vein parenteral formulas
can be as high as 1700 to 1900╯mOsm/L. High formula
osmolarity requires infusion of the formula into a large
vessel with rapid blood flow. A central line generally origi-
nates from the subclavian, internal jugular, or femoral
vein, with the tip in the superior vena cava, right atrium
of the heart, or inferior vena cava. Central line access can
also be achieved with a peripherally inserted central cath-
eter (PICC) that is inserted in the basilic vein, with the tip
in the superior vena cava or right atrium.
2. Peripheral parenteral nutrition (PPN): A smaller peripheral
vein, usually in the distal arm or hand, is used to deliver
436 PART 3â•… Introduction to Clinical Nutrition

less-concentrated solutions for periods less than 14 days. availability of central intravenous access.7 The cost of PN is
Osmolarity of PPN is limited to 900╯mOsm/L or less to generally more than that of enteral feeding, and institutions
reduce risk of thrombophlebitis in smaller vessels of the has demonstrated cost savings when inappropriate use of PN
upper distal extremities.65 have been decreased.69,70 Patients must have central intrave-
nous access to receive PN, with one port designated exclu-
Parenteral Nutrition Development sively for PN. Thus careful assessment of each situation
The pioneering work of American surgeons such as Jonathan should weigh benefits and burdens of providing PN for nutri-
Rhodes and Stanley Dudrick in the late 1960s propelled PN tion support.
from theory into reality.66 In the proceeding years, develop- Indications for PN include inability to access or the mal-
ment of the surgical technique, equipment, and solutions to function of the GI tract. Patients may have inadequate
meet nutritional requirements of catabolic illness and injury, absorption of nutrients in the GI tract because of reduced
as well as development of certain antibiotics and diuretics, bowel length or inflammation. Examples of indications for
led to its widespread use and continuing development.26,67 PN PN are obstruction, fistula, severe inflammation, intractable
was preferentially used to treat critically ill patients until a vomiting or diarrhea, or GI bleeding (see Box 19-4). If the GI
resurgence in EN in the 1990s, when more was learned about tract is functional but the patient cannot or will not consume
the importance of maintaining GI integrity. PN is associated sufficient nutrients orally, then enteral tube feeding should
with potentially serious mechanical, metabolic, and GI com- be considered. Many conditions that had been previously
plications (see Box 19-3). PN should be used judiciously to thought to be an indication for PN are treated with enteral
minimize the risks involved. PPN can be used in many cases tube feeding, such as pancreatitis, severe malnutrition, ileus,
as a viable alternative for brief periods for patients without and coma.
central vein access.68
Basic factors govern decisions about use of PN: availability
and functional capacity of the GI tract, prognosis, and
Internal Internal
jugular vein jugular vein
External External
BOX 19-6 EXAMPLE OF A BASIC jugular vein jugular vein
PARENTERAL NUTRITION Subclavian Subclavian
FORMULA FOR A 65-kg vein vein
PATIENT PROVIDING Superior
APPROXIMATELY 25╯kcal/kg vena cava
AND 1.2╯g PROTEIN PER Brachial vein
KILOGRAM Brachial
Right atrium vein
Base Solution
Basilic vein Basilic
70% Dextrose 350╯mL 245╯g 833╯kcal
vein
10% Amino acids 800╯mL 80╯g 320╯kcal
Inferior
20% Lipid 250╯mL 50╯g 500╯kcal vena cava
TOTAL 1400╯mL 1653╯kcal
Femoral Femoral
Additives vein vein
Standard Electrolytes Amount per day
╅ Sodium chloride 20╯mEq
╅ Sodium acetate 50╯mEq
╅ Potassium chloride 30╯mEq
╅ Potassium 30╯mEq (20╯mmol
phosphate phosphorus)
╅ Calcium gluconate 10╯mEq
╅ Magnesium sulfate 10╯mEq FIGURE 19-3╇ Sites of central venous access for parenteral
Multivitamin 10╯mL nutrition (PN). (From Fuhrman MP: Management of complica-
preparation tions of parenteral nutrition. In Matarese LE, Gottschlich MM,
Trace element 1╯mL editors: Contemporary nutrition support practice: a clinical
preparation guide, Philadelphia, Pa., 1998, Saunders.)

Medications
Regular insulin Only with hyperglycemia
H2-antagonists Dose depends on H2- KEY TERM
antagonist and renal fistulaâ•… Abnormal connection between two internal organs,
functions an internal organ and the skin, or an internal organ and a body
Famotidine 40╯mg cavity.
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition
Candidates for Parenteral Nutrition
PN should be reserved for patients unable to receive or toler-
ate adequate nutrients via the enteral route. On the basis of
these general considerations, a number of clinical situations
suggest a need for aggressive PN support:
• Preoperative nutrition intervention: This measure may
benefit moderately to severely malnourished patients who
can receive nutrition support for a minimum of 7 to 14
days preoperatively.7 PN should be given only if EN
support is not feasible or tolerated. The Veterans Affairs
Cooperative Study28 demonstrated the greatest benefit of
perioperative PN was experienced by severely malnour-
ished patients. Third-party payers do not routinely pay for
preoperative nutrition support.
• Postoperative surgical complications: Complications that
often result in initiation of PN are prolonged paralytic
ileus and obstruction; stomal dysfunction; short-bowel
syndrome; enterocutaneous, biliary, or pancreatic fistula;
chylothorax; chylous ascites; and peritonitis. However,
reports exist of successful enteral feeding with short-bowel
syndrome, fistula, and chylous leaks when patients are
given an elemental or semielemental, low-fat enteral
formula.71-73 PN is not indicated in patients who can
resume EN within 7 to 10 days postoperatively.7
• Bowel inflammation: Intractable gastroenteritis, regional
enteritis, ulcerative colitis, extensive diverticulitis, and
radiation enteritis may require PN if the GI inflammation
is severe and prolonged.7 Studies have shown that in some
cases enteral feeding can be feasible and beneficial in dis-
eases with bowel inflammation.74
• Malabsorption: Nutrient losses and interference with
nutrient absorption occur with chemotherapy and radia-
tion therapy. The malabsorption that is associated with
severe GI inflammation, acute severe pancreatitis, and
massive burns can exceed the ability to meet nutrient
requirements enterally.
Peripheral Parenteral Nutrition
Generally, decisions to use PPN instead of CPN are based on
energy demands, anticipated time of use, and availability of
intravenous access. Characteristics of PPN include caloric
value generally less than 2000╯kcal/day, of which 50% to
60% is provided by lipids; infusion volume of 2 to 3╯L (dilu-
tion of the formula is required for peripheral vein tolerance);
and use of infusion for less than 14 days.68 PPN cannot be
used when the patient has problems with fluid retention or
hyperlipidemia.
PARENTERAL SOLUTIONS
Parenteral Nutrition Prescription
The PN prescription and plan of care are based on the calcu-
lation of basic nutritional requirements plus additional needs
resulting from the patient’s level of illness or injury, malnutri-
tion, and physical activity. An example of a basic PN formula
is shown in Box 19-6. The same principles of nutrition
437
therapy are applied whether the patient is fed enterally or
parenterally. Nutritional needs are fundamental—energy,
protein, electrolytes, minerals, and vitamins. Guidelines are
available that address PN labeling, compounding, formula-
tions, stability, and filtering.75 The guidelines are designed to
reduce errors and complications in prescribing, preparing,
labeling, and infusing parenteral solutions.
Preparation of the Parenteral Nutrition Solution
A variety of PN component solutions exist, with varying
concentrations and nutrient compositions. Standard compo-
nents of PN can include dextrose, lipids, amino acids, elec-
trolytes, vitamins, minerals, and medications. Although PN
is compounded with modular components and hence there
is an ability to adjust dextrose, lipid, and protein independent
of each other, the energy provided to meet estimated or mea-
sured energy needs should include total energy (kcalories)
from carbohydrate, fat, and protein (Table 19-3). Estimated
and measured energy equations are based on total energy
(kcalories) requirements.
Protein-Nitrogen Source
Nitrogen is supplied by essential and nonessential crystalline
amino acids in the PN solution. Standard commercial amino
acid solutions range in concentration from 3% to 20%. Stan-
dard amino acid solutions are appropriate for almost all adult
patients receiving PN. Protein has an energy value of 4╯kcal/g
(see Table 19-3) and usually provides 10% to 20% of the total
energy provided in PN.
In addition to standard amino acid solutions, three types
of specialized amino acid solutions have been formulated for
specific disease states. The two disease-specific formulas
are more expensive than standard solutions, and their effec-
tiveness has not been demonstrated. One type is enriched
with the branched-chain amino acids (BCAAs) isoleucine,
leucine, and valine, and is designed for patients with liver
failure. A renal failure formula contains only essential amino
acids to prevent the development of hyperuremia. Neither
disease-specific formula has been found to improve out-
comes in these patient populations.7 Infusion of BCAA may
be beneficial in a very small population of patients with
TABLE 19-3 CALORIC VALUE PER
MILLILITER OF
PARENTERAL
COMPONENTS
NUTRIENT CONCENTRATION (%) kcal/mL
Dextrose 70.0 2.38
50.0 1.85
Lipids 30.0 3.0
20.0 2.0
10.0 1.1
Amino acids 15.0 0.6
10.0 0.4
8.5 0.34
438 PART 3â•… Introduction to Clinical Nutrition
chronic hepatic encephalopathy that is unresponsive to drug
therapy.7 The third type of specialized amino acid formula is
designed specifically for the needs of pediatric patients and
is selected based on the age and nutrient requirements of
the child.
Carbohydrate-Dextrose
Dextrose is the most common and least expensive source of
energy used for PN support. Dextrose is available in concen-
trations ranging from 2.5% to 70%. Hypertonic solutions of
50% to 70% dextrose are often used in PN formulations and
provide 50 or 70╯g of dextrose per 100╯mL, respectively.
Glucose used in PN support is commercially available as dex-
trose monohydrate (C6H12O6H2O), which has an energy value
of 3.4╯kcal/g versus the energy value of 4╯kcal/g of dietary
glucose (C6H12O6). The caloric values of dextrose solutions
are given in Table 19-3. The initial dextrose content of PN
should not exceed 200╯g. Gradual introduction of dextrose
enables the clinician to evaluate blood sugar response and, if
necessary, institute insulin therapy. The amount of dextrose
provided is increased to goal according to patient tolerance
and should not exceed 5╯mg/kg/min.
Glycerol is another form of carbohydrate used in paren-
teral solutions. It provides 4.3╯kcal/g and is available as a
component along with amino acids in a commercially avail-
able PPN solution.
Fat-Lipids
Lipid emulsions provide a concentrated energy source,
9╯kcal/g, as well as the essential fatty acids linoleic and lino-
lenic acid. A minimum of 4% to 10% of the daily energy
intake should consist of fat to prevent essential fatty acid
deficiency. Lipids are available in 10% (1.1╯kcal/mL), 20%
(2╯kcal/mL), and 30% (3╯kcal/mL) products (see Table 19-3).
A 500-mL bottle of 10%, 20%, or 30% fat emulsion provides
550, 1000, and 1500╯kcal, respectively. Commercial lipid
emulsion products consist of soybean and safflower oils com-
bined or soybean oil alone. The content of lipid in a paren-
teral solution is usually limited to 20% to 30% of total energy
because lipids have been reported to adversely affect the
immune system.76 However, infusion of lipids over 24 hours
may limit this adverse effect. Research on alternative lipid
sources includes forms such as short-chain fatty acids,
medium-chain fatty acids, omega-3 fatty acids, and blended
or structured lipids. However, these alternatives are not avail-
able for commercial use in the United States. Lipid emulsions
can be infused separately through the Y-port of the intrave-
nous catheter (piggybacked) or combined with the dextrose
and amino acid base in what is called a total nutrient admix-
ture (TNA) or 3-in-1.75
Electrolytes
The body maintains a balance of fluid and electrolytes in
intracellular and extracellular spaces of all tissues to maintain
homeostasis (see Chapter 7). Electrolyte status is affected by
disease state and metabolic condition of the patient. Electro-
lytes in PN formulas are based on normal electrolyte balance
with adjustments according to individual patient require-
ments. Electrolytes should be routinely monitored to deter-
mine electrolyte requirements in PN.
In general, basic electrolyte recommendations are shown
in Table 19-4, with chloride and acetate balanced among
the salts. Commercial amino acid formulations are available
with or without added electrolytes. Amounts of electrolytes
present in the amino acid solution must be taken into account
when calculating additions of electrolytes for a specific
patient. Guidelines for electrolyte management include the
following:
1. Identify and correct any preexisting deficits before initiat-
ing PN.
2. Determine the cause of electrolyte abnormalities.
3. Replace excessive fluid and electrolyte losses.
4. Monitor and assess electrolyte status daily.
Depending on requirements for electrolyte replacement, it
may be necessary to give additional electrolytes outside the
PN, because limitations exist regarding what can be added to
a parenteral solution based on solution stability and compat-
ibility.72 Selected electrolytes can be omitted from the paren-
teral solution when serum levels exceed normal values, such
as potassium and phosphorus with renal failure. Electrolyte
levels should be checked in all patients before starting PN and
routinely throughout PN therapy.
Vitamins
Vitamin requirements are based on normal standards (see
Chapter 6), with adjustments made according to metabolic
states that require either more or less of a specific vitamin.
All patients on PN should receive vitamins daily. Serum
levels of vitamins should be monitored in patients requir-
ing long-term PN or when deficiencies or excesses are
suspected.
The Nutrition Advisory Group of the American Medical
Association has established guidelines for parenteral admin-
istration of 12 vitamins: A, D, E, thiamin, riboflavin, niacin,
pantothenic acid, pyridoxine, folic acid, biotin, cyanocobala-
min, and ascorbic acid (see Table 19-4).77 Multivitamin infu-
sion preparations based on these guidelines are commercially
available. Vitamin K has not historically been a component
of any injectable vitamin formulation for adults. The FDA
mandated changes in parenteral vitamin formulations that
included addition of 150╯mcg of vitamin K to injectable mul-
tivitamin preparations.78 It will be important to monitor
International Normalized Ratio (INR) levels, particularly for
patients on anticoagulation therapy started or stopped on PN
containing vitamin K. An injectable multivitamin prepara-
tion without vitamin K is also available.
KEY TERM
admixtureâ•… A mixture of ingredients that each retain their
own physical properties; a combination of two or more sub-
stances that are not chemically united or that exist in no fixed
proportion to each other.
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition 439

TABLE 19-4 MICRONUTRIENTS AND Trace Elements

PARENTERAL NUTRITION The American Medical Association has set guidelines for the
FOR ADULTS addition of four trace elements in PN solutions: zinc, copper,
manganese, and chromium (see Table 19-4).79 Trace element
STANDARD DAILY
MICRONUTRIENTS AMOUNTS preparations are available with combinations of the afore-
mentioned four trace elements only, the standard four plus
Electrolytes
Potassium (K) 1-2╯mEq/kg
selenium, or the standard four plus selenium, molybdenum,
Sodium (Na) 1-2╯mEq/kg and iodine. Each trace element is also available as a single
Phosphate (HPO4) 20-40╯mmol injectable mineral product. A growing amount of literature
Magnesium (Mg) 8-20╯mEq demonstrates the importance of providing selenium to PN
Calcium (Ca) 10-15╯mEq patients who are critically ill80,81 and those who require long-
Acetate Balance with chloride to term PN.82 Iron is not routinely added to PN because of
maintain acid-base balance incompatibility with intravenous lipids, as well as the poten-
Chloride Balance with acetate to tial adverse effects of iron dextran. Other forms of intrave-
maintain acid-base balance nous iron have less adverse effects but are not approved for
Vitamins
addition to the PN solution. Intravenous iron should only be
Vitamin A 3300╯IU given to patients with iron deficiency anemia and adminis-
Vitamin D 200╯IU tered apart from the PN admixture or added to a 2-in-1 PN
Vitamin E 10╯IU solution.75 A dose of 25 to 50╯mg of iron dextran once a
Vitamin K 150╯mcg month should be sufficient to meet iron needs in a patient
Thiamin (B1) 6╯mg without blood loss.75
Riboflavin (B2) 3.6╯mg Patients on long-term PN without trace element supple-
Niacin (B3) 40╯mg mentation are at risk for micronutrient deficiencies.82,83 In
Folic acid 600╯mcg addition, reports exist of excess trace element levels with infu-
Pantothenic acid 15╯mg
sion of standard trace element preparations.84 Patients who
Pyridoxine (B6) 6╯mg
require long-term PN should be routinely monitored for
Cyanocobalamin (B12) 5╯mcg
Biotin 60╯mcg potential trace element deficiencies and toxicities.
Ascorbic acid (vitamin C) 200╯mcg
Medications
Trace Elements Medications often added to PN include insulin, H2-
Chromium 10-15╯mcg antagonists, heparin, metoclopramide, and octreotide. Inclu-
Copper 0.3-0.5╯mcg sion of these medications and others will depend on each
Iodine Not routinely provided institution’s guidelines and protocols for addition of medica-
50╯mcg for pregnant women
tions to PN solutions. Many issues exist concerning compat-
Iron Not routinely provided
25-50╯mg per month without
ibility, bioavailability, efficacy, interactions, and safety when
blood loss including medications in PN solutions. Consult a pharmacist
Manganese 60-100╯mcg whenever considering the addition of a medication to PN
Selenium 20-60╯mcg solutions.
Zinc 2.5-5.0╯mg
Molybdenum Not routinely provided
PARENTERAL NUTRITION DELIVERY SYSTEM
Data from Fuhrman MP: Complication management in parenteral
nutrition. In Matarese LE, Gottschlich MM, editors: Contemporary
Equipment
nutrition support practice: a clinical guide, ed 2, Philadelphia, Pa., Strict aseptic technique throughout PN administration by all
2003, Saunders; Task force for the revision of safe practices for health care personnel is absolutely essential. This includes (1)
parenteral nutrition: Safe practices for parenteral nutrition. JPEN J solution preparation by the pharmacist, (2) surgical place-
Parenter Enteral Nutr 28(suppl):S39, 2004; American Medical
Association, AMA Department of Foods and Nutrition: Multivitamin
ment of the venous catheter by the physician, (3) care of the
preparations for parenteral use: a statement by the Nutrition catheter site and all external equipment, and (4) administra-
Advisory Group. JPEN J Parenter Enteral Nutr 3:258, 1979; tion of the solution by the nurse. At every step of the PN
Parenteral multivitamin products; drugs for human use; drug process, strict infection control is a primary responsibility of
efficacy study implementation; amendment (21 CFR 5.70). Fed all health care professionals.
Register 65:21200, 2000; Expert Panel for Nutrition Advisory
Group, AMA Department of Foods and Nutrition: Guidelines for
essential trace element preparations for parenteral use. JAMA
Venous Access
241:2051, 1979. Surgical placement of the venous catheter is done by the
physician at the bedside or in a surgical suite, using local or
general anesthesia. Intravenous catheters are available with
single, double, triple, or quadruple lumens. Inconsistent data
440 PART 3â•… Introduction to Clinical Nutrition
exist as to whether the number of lumens contributes to
the risk of catheter-related infection.85-87 Catheters are also
categorized as either temporary or permanent. Temporary
catheters involve a direct percutaneous puncture into a
major vessel and are used short-term during hospitalization.
Permanent catheters are designed for long-term use and
are available as implanted ports, tunneled catheters, and
PICCs. The tip of a central venous catheter is located in the
inferior or superior vena cava, which leads directly into
the heart (see Figure 19-3).64 Placement of the catheter tip
in the vena cava allows infusion of concentrated solutions,
five times the concentration of blood plasma, to be infused
at a rate of 2 to 3╯mL/min. Hypertonic solutions are imme-
diately diluted by the large blood flow of 2 to 5╯L/min in the
vena cava.
Catheter-related sepsis is a serious complication, particu-
larly with the increase in colonization of resistant strains of
microorganisms that limit available treatment options.
Antibiotic-impregnated catheters and dressings are available
and are associated with reduced catheter-related septic
complications.88-90 Filters (0.22╯µm) on intravenous catheter
tubing prevent infusion of not only particulate matter but
also certain microorganisms.75 However, a larger filter
(2.1╯µm) that is less effective against microorganisms must
be used with PN containing lipids. Clinicians must use
aseptic technique when inserting and caring for intravenous
catheters.
Solution Infusion and Administration
Volumetric infusion pumps should be used to deliver the
parenteral solution at a constant rate to prevent metabolic
complications. Protocols for external delivery system tubing
changes are provided by infection control guidelines. Routine
flushing of intravenous catheters is recommended to main-
tain catheter patency. Needleless intravenous access devices
reduce risk of needlestick injuries but can increase risk of
catheter-related infections. According to the Intravenous
Nurses Society standards of practice, needleless devices
should be changed every 24 hours, the injection port
should be disinfected with alcohol before accessing, and all
junctions should be secured with Luer-Lok, clasps, or threaded
devices.91
Infusion of PN is generally over 24 hours, particularly in
the critically ill. PN is usually cycled for patients at home or
who need “time off ” during hospitalization for physical
therapy or other routine activities. PN can be cycled over 10
to 12 hours if desired and if the patient can tolerate the larger
volume over a shorter period. The rate of infusion is based
on the final compounded volume and length of time the
infusion is to be given. Administration of PN should be
adjusted based on the patient’s response and tolerance to the
regimen (see the Perspectives in Practice box, “Parenteral
Nutrition Administration”). When PN is being discontinued,
the infusion rate should be cut by one half for 1 hour and
then stopped. Abrupt interruption of PN infusion may
require hanging 10% dextrose to prevent possible rebound
hypoglycemia.75
╇ PERSPECTIVES IN PRACTICE
Parenteral Nutrition Administration
Of all the various ways of nourishing the human body—
normal eating, liquid diets, enteral nutrition (EN), and paren-
teral nutrition (PN)—PN requires the highest level of skilled
and precise administration. A risk of potentially life-threatening
complication and infection exists. Trained nutrition support
clinicians are central to the success of PN. The nutrition
support nurse administers the PN solution according to the
nutrition support team protocol, monitoring the entire PN
system frequently to see that it is operating accurately.
Specific clinical protocols will vary somewhat, but they
usually include the following points:
• Schedule carefully: PN volume can vary from 1 to 3╯L and
should be infused with an infusion pump. The infusion
rate is based on the total volume of the compounded
solution.
• Monitor closely: Note metabolic effects of glucose and
electrolytes. Blood glucose levels should not exceed
200╯mg/dL during initiation of PN and should not exceed
110 to 150╯mg/dL when the patient is stable on the
formula. First-day formulas generally contain no more than
200╯g dextrose. Monitor glycemic tolerance closely, par-
ticularly the first couple of days, as the feeding is advanced.
Electrolyte status and glucose levels should be determined
before and throughout PN administration. Increase energy
provision only as patient tolerates macronutrient content.
• Make changes cautiously: Monitor and report the effect of
all changes, and proceed slowly.
• Maintain a constant rate: Keep to the correct hourly infu-
sion rate, with no “catch-up” or “slow-down” effort to
meet the original volume order.
• Discontinue PN: Reduce the rate by one half for 1 hour
before discontinuing. If patient has had insulin added to PN
and is not receiving enteral tube feeding, then monitor for
rebound hypoglycemia (check serum glucose 2 hours after
stopping PN infusion).
Monitoring
Complications of PN include catheter, GI, and metabolic
problems (see Box 19-3). In the hands of well-trained PN
clinicians, risks can be minimized and complications con-
trolled.92 Specific evidence-based protocols, updated periodi-
cally, guide continuing assessment and monitoring.93 Every
patient on PN should undergo a routine nutrition reassess-
ment with adjustments made in the feeding regimen accord-
ing to the patient’s metabolic and nutritional needs. Every
effort should be made to transition the patient from PN to
enteral tube feeding or oral diet whenever feasible or appro-
priate. Providing at least a portion of energy via the GI tract
may help reduce the adverse effects associated with PN.64
HOME NUTRITION SUPPORT
Patients who are discharged with home nutrition support
and those who started on nutrition support while in the
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition
home require special consideration. Several factors must be
evaluated to ensure that the home environment is safe and
the patient and family are able and willing to accept the
responsibility of home infusion therapy. The home should
have refrigeration, running water, electricity, and adequate
storage for supplies. The patient and family must be capable
of and willing to learn techniques required to administer and
manage the feeding access. It is also important that the patient
and family accept responsibility to comply with the infusion
regimen so that the patient receives nutrients as prescribed.
Ongoing communication occurs among the patient, physi-
cian, and home infusion provider, but ultimately the patient
must self-manage the therapy and work closely with the
home nutrition support team. The Oley Foundation
(www.oley.org) provides a network of support for patients on
chronic, long-term home enteral and parenteral therapies.
Reimbursement for services must be confirmed before
sending a patient home on nutrition support. The process
can require additional diagnostic testing and documentation
in order for the patient to qualify, particularly when Medicare
is the source of reimbursement.
Home Enteral Tube Feeding
Patient Selection
Developments in enteral tube feeding formulas and portable,
lightweight infusion equipment have simplified home tube
feeding and made it easier to manage. As a result, the number
of patients who receive home tube feeding continues to grow
as a means of cutting hospital costs and allowing earlier
family support at home. The success of home infusion of
enteral tube feeding relies on the education and training of
patient and family.94
Teaching Plan
Educating the patient and family for home infusion of enteral
tube feeding is a team responsibility. This team may be hos-
pital based or affiliated with the home infusion company that
will manage the patient’s care after discharge. The RD, nurse,
and pharmacist develop and carry out a teaching plan, which
includes topics and related tasks in preparing patients and
families for discharge on home enteral feeding (Box 19-7).89
The goal is to promote self-care and monitoring.
The hospital or home infusion company should provide a
teaching manual with illustrations to guide the teaching-
learning process and that can be used as a reference at home.
The teaching plan should start as soon as the decision for
home tube feeding is made. A social worker identifies and, if
possible, resolves any personal, psychosocial, safety, or eco-
nomic issues with home infusion.
Finally, the teaching plan should allow sufficient time
before discharge for the patient and family to demonstrate
competency in administering the tube feeding formula and
recording all necessary information about formula and fluid
intake, formula tolerance, and complications. Directions for
recording information are included in the home infusion
manual. Records are reviewed regularly by the home nutri-
tion support team and the patient’s physician.
441
BOX 19-7 HOME ENTERAL TUBE
FEEDING EDUCATION
TOPICS AND TASKS
• Which enteral formulation is used and why
• How to prepare the tube feeding formula for infusion
• How to infuse the formula through the feeding tube
• How to correctly use and troubleshoot problems with the
equipment
• How much water and how often to flush the feeding tube
• How to care for the tube site
• How to recognize tube feeding formula intolerance
• How to avoid and treat complications
• How to give medications and other separate nutrients
through the feeding tube
• When to call the physician or home infusion provider
Follow-up Monitoring
The plan for follow-up monitoring should be guided by spe-
cific protocols developed by the home infusion provider for
laboratory, clinical, and home nutrition assessments. The
home nutrition support team checks the patient’s progress
and works with the patient and family to troubleshoot any
problems that arise and make required adjustments in the
formula or tube feeding plan. Whenever feasible and appro-
priate, the RD works closely with the patient and family to
transition from tube feeding to oral intake. A study by Silver
and colleagues95 reported older adults who received home
enteral tube feeding with no consistent clinical follow-up
experienced complications associated with unscheduled
health care visits and readmissions to the hospital. This study
demonstrated the potential for improving outcomes with
more frequent monitoring, reassessment, and intervention by
a home nutrition support team that includes an RD.
Home Parenteral Nutrition
The patient sent home with PN requires education and train-
ing on the provision of PN in the outpatient setting. In the
hands of knowledgeable and capable patients and their fami-
lies, home PN allows mobility and independence. Equipment
used in the home is small and portable, fitting in a backpack
and allowing patients to resume normal activities. The patient
and family must be trained to use aseptic technique for
adding micronutrients and medications to the solution and
for accessing the intravenous catheter or port. Special equip-
ment, solutions, and guidelines for training and supervising
patients and families have been developed and are success-
fully used by hundreds of patients. Ongoing assessment of GI
function must be performed to determine if the patient is
ready to transition to enteral feedings (either oral or via
feeding tube). Patients are also monitored closely for the
development of complications associated with long-term PN
infusion.
A study in complex inflammatory bowel disease patients
demonstrated home PN could be successfully used to delay
442 PART 3â•… Introduction to Clinical Nutrition
or avoid surgery.96 The study also found anxiety about man-
aging PN at home decreased for most of the patients after 1
week at home.
HEALTH PROMOTION
TROUBLESHOOTING DIARRHEA
IN TUBE-FED PATIENTS
Diarrhea is one of the most common complications associ-
ated with tube feeding, yet the reported incidence ranges
widely, from as little as 2% to as much as 70% in general
patient populations to as high as 80% in ICU patients. Ques-
tions that relate to this wide variance and that plague inves-
tigators apparently center on definition and cause. However,
the ultimate bottom line for patients, their families, and
health insurers is the cost of the clinical search for the cause
of diarrhea in these patients and the appropriate method of
treatment. Although clinicians search for an effective treat-
ment, diarrhea results in reduced energy intake, dehydration,
electrolyte abnormalities, and skin breakdown. Diarrhea
also causes the patient discomfort, embarrassment, and
frustration.
Problem of Definition
Several definitions of enteral feeding–related diarrhea have
been used in the literature. However, little agreement exists
concerning which definition most accurately reflects diarrhea
that requires intervention. Common definitions include
output of more than 500╯mL on 2 consecutive days or more
than three stools per day. From a nursing standpoint, collec-
tion and measurement of stool outputs are much less desir-
able than tracking the number of occurrences. However, the
true definition of diarrhea may need to reflect consistency
and volume and not just the number of stools per 24 hours.
Most institutions do not have a standard definition for diar-
rhea; therefore in most cases, diarrhea is defined by the
person cleaning it up. Diagnosis of the cause of diarrhea
and subsequent treatment consume time and health care
resources. Meanwhile the patient is losing fluid, electrolytes,
and nutrients through uncontrolled stool output. This can
further exacerbate impaired nutritional status. Diarrhea not
only takes a physical and nutritional toll on the patient but
also has a psychologic effect of embarrassment and humilia-
tion from an inability to control bodily functions and the loss
of privacy.
A recently reported case of unexplained diarrhea in a tube-
fed patient illustrates the difficult—and often expensive—
search for the cause (see the Case Study box, “Case of the
Costly Chase”).
Factors Contributing to Diarrhea
Reported causes of diarrhea in tube-fed patients also
vary. The finger of blame for diarrhea usually is aimed at
the tube feeding formula. This results in manipulation
of the formula—selection and concentration and infusion
methods—usually to no avail because feeding intolerance is
generally a manifestation, not the cause, of diarrhea. A variety
of causes for diarrhea have been reported. The most common
contributors to diarrhea in tube-fed patients are medications
or some aspect of the patient’s condition. However, many
times a combination of events or therapies (not a single con-
tributor) results in diarrhea.53,54,87-100
Formula
Tube feeding formula osmolality or concentration and rate
of delivery are often blamed for instigating diarrhea. However,
reports have shown no increase in the incidence of diarrhea
when the formula concentration varied widely from 145 to
430╯mOsm/L, and no significant association has been made
between malabsorption and formula osmolality or rate of
delivery. Formulas that provide more than 30% of total kcalo-
ries as fat have been associated with an increased incidence
of diarrhea, whereas those providing 20% fat rarely were
involved. Further study of fat composition is needed, specifi-
cally comparing medium-chain triglycerides (MCTs) versus
long-chain triglycerides (LCTs) and omega-3 versus omega-6
fatty acids. Studies of the role of fiber in tube feedings have
had conflicting results. No consistency is seen in the types and
amount of fiber in enteral tube feeding formulas. Soluble
fiber can increase colonic absorption of water. However,
when the fiber given to a patient is increased rapidly, the
patient will experience flatulence, abdominal distention, and
constipation. Reviewers have found that studies thus far have
been few, the models used have been variable, limitations
were substantial, and the conclusions of investigators were
mixed. In general, the amount and type of fiber in enteral
formulas are not significant enough to prevent or contribute
to diarrhea.53,54,97-100
Bacterial Contamination
Studies have shown the more manipulation and additives,
such as modular components, that are added to an enteral
formula, the more likely the formula will become contami-
nated. Tube feeding formula hang time, open versus closed
delivery systems, and preparation technique can affect the
risk of bacterial contamination of the enteral tube feeding
formula. Formula added to open delivery systems should
hang no longer than 8 hours (and for even shorter periods of
time if additives are combined with the formula). Closed
systems that use containers prefilled with formula can hang
24 to 48 hours. The fewer times any system is handled and
opened, the less chance exists for contamination. Commercial
formula manufacturers are making formulas now that contain
microbial inhibitors to reduce the risk of bacterial contami-
nation of the enteral formula itself.53,54,97-100
Infusion Method
Intragastric feedings are associated with an increased inci-
dence of diarrhea. Infusion of a large amount of energy into
the stomach stimulates the colon to secrete water, sodium,
 CHAPTER 19â•… Nutrition Support: Enteral and Parenteral Nutrition
CASE STUDY
Case of the Costly Chase
A reported case of unexplained diarrhea in a tube-fed patient
illustrates the difficult, and often costly, search for the cause.
Max was a 55-year-old man who had had an aortic aneurysm
and undergone emergency surgery to repair it. In the intensive
care unit (ICU), the postoperative course was complicated by
respiratory problems requiring ventilator assistance. He was
administered a bronchodilator drug, theophylline, in tablet
form, crushed and administered by nasogastric tube with
water. When Max was started on an enteral tube feeding with
an isotonic formula, crushed theophylline tablets were changed
to a sugar-free theophylline solution. Within a day Max began
to have progressive abdominal distention and continuous liquid
diarrhea. To rule out an abdominal catastrophe related to the
aneurysm or surgery, a computed abdominal tomography scan,
an aortogram, and colonoscopy were performed, but all of
these studies produced normal results.
Despite stopping the enteral tube feeding, the distention and
diarrhea continued. Stool specimens were tested for fecal leu-
kocytes, parasites, and Clostridium difficile toxin, and an enteric
pathogen culture was prepared. All were nondiagnostic. Exten-
sive additional serum and urine tests, as well as a sigmoidos-
copy with rectal biopsy, gave no clue. Then stool electrolytes
and osmolality measures suggested an osmotic diarrhea.
Because Max was not receiving enteral tube feedings, his
physicians thought a secretory bacterial toxin was probably
causing continuing diarrhea, so the previous studies were
repeated to confirm the osmotic nature of the diarrhea. In addi-
tion, all medications were reviewed, but none appeared to be
the cause.
Because the continued diarrhea prohibited enteral tube
feeding and Max needed to be fed, parenteral nutrition (PN)
was ordered. This move immediately brought an automatic
nutrition support service consultation, which included
Data from Wong K: The role of fiber in diarrhea management. Support Line 20:16, 1998.
and chloride with resulting inability of the colon to absorb
nutrients.53,54,97-100
Patient’s Condition
Malnourished or critically ill patients are more susceptible to
mucosal tissue breakdown and malabsorption leading to
diarrhea. Hypoalbuminemia has also been reported to be a
potential cause of diarrhea because of its effect on reducing
colloidal osmotic pressure within blood vessels, which could
lead to edema of the intestinal mucosa, malabsorption, and
diarrhea. However, no correlation has been found between
patients with hypoalbuminemia and incidence of diarrhea.
Patients with pancreatic insufficiency, celiac disease, short-
bowel syndrome, fecal impaction, diabetes mellitus, or GI
inflammation are at increased risk for diarrhea.53,54,97-100
Medications
Multiple medications routinely given to hospitalized patients
have been related to diarrhea. Antibiotics are most often
443
assessment of medications. This evaluation revealed that the
sugar-free theophylline solution was 65% sorbitol.
Sorbitol is a polyhydric alcohol used as a sweetener in
many sugar-free products such as dietetic foods and chewing
gum. Because sorbitol is considered an “inactive” ingredient,
the package label and insert contained no information
about it. Sorbitol content was obtained by contacting the
manufacturer.
Fortunately for Max, however, the nutrition support team did
know the components of the medication and found the hidden
culprit. The registered dietitian (RD) knew sorbitol in larger
doses acted as a laxative. Calculations of the regular daily
amount of theophylline Max was taking showed he was receiv-
ing nearly 300╯g of sorbitol daily when the usual laxative dose
was only 20 to 50╯g. The nutrition support team immediately
recommended that this sorbitol-sweetened solution of theoph-
ylline be discontinued and a sorbitol-free form of the medica-
tion be used instead. Almost immediately the diarrhea began
to decrease, and in 3 days it was gone.
The extent of this costly chase was revealed in Max’s hospital
bill. He had continued to receive the faulty drug for almost half
of his 3-month hospital stay, during which time the diarrhea
prevented enteral tube feeding and he had to have the more
expensive PN. The PN cost $5000 more than enteral feedings
would have cost for the same period. In addition, all the exten-
sive investigations to find the cause of the diarrhea cost $5300,
which together with the indirect costs for extra days of care
and supplies made a total hospital bill of about $200,000.
Causes of diarrhea in tube-fed patients are many, but in the
hands of a skilled nutrition support team, the formula is seldom
one of them. It is often found in the medications. Just remem-
ber what this medication’s hidden ingredient—sorbitol—cost
Max.
associated with GI side effects. However, patients more
susceptible to developing diarrhea are those who are critically
ill and on multiple medications. Extensive treatment with
antibiotics and disuse of the GI tract contribute to a change
in the bacterial milieu of the intestine, with proliferation of
the enteric pathogen Clostridium difficile. Other medications
associated with development of diarrhea are H2-blockers,
lactulose or laxatives, magnesium-containing antacids, potas-
sium and phosphorus supplements, antineoplastic agents,
and quinidine. Medications are often hyperosmolar and
require dilution before infusion through a feeding tube.
In general, drug reactions may relate to the metabolically
active agent or to another ingredient added for its physical
properties in the form of the drug, such as tablet or liquid
(as the case in the Case Study box illustrates). Probiotics,
nonpathogenic lactic acid bacteria, are receiving more
attention as a potential treatment of diarrhea and as a
means of preventing bacterial overgrowth and C. difficile
infections.53,54,97-100
444 PART 3â•… Introduction to Clinical Nutrition
TO SUM UP
For patients with functioning GI tracts, EN support has
proved to be a potent tool against present or potential mal-
nutrition. EN support is achieved by an oral diet with
nutrient-dense supplementation or alternately by tube
feeding when the patient cannot, will not, or should not eat.
Commercial tube feeding formulas with or without modular
enhancement provide complete nutrition when provided in
adequate amounts. Enteral tube feeding can be provided
through nasoenteric or enterostomy feeding tubes with an
open or closed delivery system. Tubing and container adapta-
tions and development of small, mobile infusion pumps,
together with a comprehensive teaching plan for patient and
QUESTIONS FOR REVIEW
1. Describe several types of patient situations in which
enteral tube feeding may be indicated. What nutrition
assessment procedures may help to identify these
individuals?
2. Describe nutrient components of a typical complete poly-
meric enteral formula. How does it differ from a modular
formula? How does it differ from a semielemental and an
elemental formula?
3. Define PN, and identify examples of conditions in which
it would be used.
The following questions apply to the case of a man referred
to nutrition support services. Imagine you are caring for this
patient.
While on a long transport haul as a truck driver, a previ-
ously healthy 45-year-old man was in an accident in which
he sustained a severe abdominal injury that required exten-
sive surgical repair and left the GI tract unavailable for use
for an undetermined period. He is referred to the nutrition
support team for PN. Early in this care he asks you how this
feeding works.
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4. How would you describe and explain the PN feeding
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5. What nutrition assessment parameters would be beneficial
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FURTHER READINGS AND RESOURCES
American Society for Parenteral and Enteral Nutrition Board of
Directors and Task Force on Standards for Specialized
Nutrition Support of Hospitalized Adult Patients, Standards for
Specialized Nutrition Support: Adult hospitalized patients.
Nutr Clin Pract 17:384, 2002.
A.S.P.E.N. Board of Directors and the Clinical Guidelines Task
Force: Guidelines for the use of parenteral and enteral
nutrition in adult and pediatric patients. JPEN J Parenter
Enteral Nutr 26(Suppl):1SA, 2002.
Heyland DK, Dhaliwal R, Drover JW, et╯al: Canadian clinical
practice guidelines for nutrition support in mechanically
ventilated, critically ill adult patients. JPEN J Parenter Enteral
Nutr 27:355, 2003.
Task Force for the Revision of Safe Practices for Parenteral
Nutrition and the A.S.P.E.N. Board of Directors: Safe practices
for parenteral nutrition. JPEN J Parenter Enteral Nutr
28(Suppl):S30, 2004.
Websites of Interest
• The American Society for Parenteral and Enteral Nutrition
(A.S.P.E.N.). An interdisciplinary organization involved in
provision of clinical nutrition therapies including parenteral
and enteral nutrition: www.nutritioncare.org.
• Academy of Nutrition and Dietetics. The world’s largest
organization of food and nutrition professionals committed to
improving the nation’s health and advancing the profession of
dietetics through research, education, and advocacy:
www.eatright.org.
• CIGNA Medicare. This site offers free Medicare training for
clinicians regarding Medicare qualifications for home enteral
and parenteral nutrition: www.cignamedicare.com/webtraining.
• Dietitians in Nutrition Support. Dietetic practitioners
integrating the science of enteral and parenteral nutrition to
provide appropriate nutrition support to individuals in
inpatient and outpatient settings: www.dnsdpg.org.
• The Oley Foundation. This nonprofit organization provides
information and psychosocial support of consumers of home
parenteral and enteral nutrition: www.oley.org.