Early Enteral Nutrition

BACKGROUND
HOSPITAL MALNUTRITION
n Even at the best hospitals in the world
n 40-45% of patients are either malnourished
or at risk of malnutrition
n Three times more likely to have complications
and excess mortality
n Longer hospital stays
n Hospital charges may increased by 35-75 %
MALNUTRITION

Strength
Resistance to infection
Ability to heal
Negative impact
HISTORY OF NUTRITION
SUPPORT
n 1600s intravenous feeding
n 1700s oral gastric feeding
n 1800s rectal feeding
n 20
th
century infusion of nutrients
n Late 1970s GIT primary route for
nutrient administration
n Since then enteral feeding whenever
feasible

INTRODUCTION
n Surgical and accidental trauma is well
known to cause a transient suppression of
the immune system, that increases the
infection risk.
n There is consensus that nutritional
support is an essential component of the
multidisciplinary treatment of surgical
and critically ill patients, especially when
the illness is associated with prolonged
catabolism and with the inability to use
the GI tract.
INTRODUCTION
n In the second half of the last century
several studies underscored the
importance of feeding surgical patients
adequately, to reduce the severity and
duration of the catabolic phase, thus
decreasing the postoperative infection
risk.
n Postoperative nutritional support benefits
the high risk surgical patients, by
decreasing surgical morbidity,
maintaining immunocompetence and
improving wound healing
Why Enteral Nutrition?
n Without enteral nutrition gut atrophy
because no nutrients for enterocyte &
colonocyte
n Inadequate enteral nutrition barrier function
failure endotoxin&bacteria translocations
GOAL: To maintain intestinal mucosal integrity
(normal microvilli and intestinal barrier,
intestinel mucosal immunity)

n The EN has a specific trophic effect on
the GI tract; such effect is potentially
valuable in preventing microbial
translocation from the gut to the blood
stream and subsequent gut derived
infection.
Time of EN ?
n Early enteral feeding is well tolerated and
it reduces significantly the rate of
postoperative complications . As a
consequence, there is now consensus that
critically ill patients are candidates to
enteral feeding if they have a functioning
GI tract

Time of EN ?
n The EN usually can begin postoperatively
as soon as the patient is
haemodinamically stable.
n Preferably it should start within 24 hours
after surgery, and no later than 48 hours.
As long as there is no significant
abdominal distension, enteral feeding is
not contraindicated, even with markedly
diminished bowel sounds. Most patients
can be fed enterally without waiting for
flatus.
Why sould be Early ?
n Immediate or early postoperative EN
stimulates the splanchnic and hepatic
circulation; it improves intestinal mucosa
blood flow, it prevents intramucosal
acidosis and permeability disturbances
and it eliminates the need for stress ulcer
prophylaxis
Definition
n delivery of nutrients directly into the
stomach, duodenum or jejunum. Called
also enteral nutrition
Enteral Tube Feeding

n Nutritional support via tube
placement through the nose,
esophagus, stomach, or intestines
(duodenum or jejunum)
Must have functioning GI tract
Exhaust all oral diet methods first.
Copyright 2000 by W. B. Saunders Company. All rights reserved.
Diagram of enteral tube placement.
Fig. 22-2. p. 468.
INDICATION
n Malnourished patient who
unable to eat >5-7 days
n Normally nourished patient
who unable to eat >7-9 days
n Adaptive phase of short
bowel syndrome
n Increased needs that cannot
be met through oral intake
(burns, trauma)
n Inadequate oral intake
resulting in deterioration of
nutritional status or delayed
recovery from illness

CONTRAINDICATION
n Severe acute pancreatitis
n High output proximal fistula
n Inability to gain access
n Intractable vomiting or
diarrhea
n Aggressive therapy not
warranted

ASPEN. The science and practice of
nutrition support. A case-Based Core
curriculum. 2001; 143
Contraindications for EN
n Inadequate resuscitation or
hypotension; hemodynamic instability
n Ileus
n Intestinal obstruction
n Severe G.I. Bleed
n Expected need less than 5-7 days if
malnourished or 7-9 days if normally
nourished

Choosing the Feeding Site

Can the GI tract be used?
No Yes
Tube feeding for more than 6 weeks?
No Yes
Nasoenteric Tube
Risk for pulmonary aspiration?
Yes No Yes No
Nasogastric Tube Jejunostomy
Parenteral Nutrition
Enterostomy Tube
Nasoduodenal
or nasojejunal tube
Gastrostomy

Gastric Access
Gastric Route Preferred
Adequate gastric motility
Minimum risk of aspiration
Gastric Route Contraindicated
Delayed gastric emptying (gastroparesis)
High risk for aspiration

Gastric Feeding Techniques

Nasogastric Tube
Short term

Manual or
radiologic
placement
Gastrostomy
Long term

Endoscopic,
radiologic, or
surgical placement
Rugeles S, et al. Universitas Medica 1993;34(I):19-23
Nasogastric Tube: Disadvantages
Short-term use only
Higher risk for aspiration
Difficult to confirm position
Small bore
Nasopharyngeal trauma/irritation
Accidental tube displacement

Percutaneous Endoscopic Gastrostomy:
PEG Tubes

Rigid
Flexible
Minard G. Nutr Clin Prac 1994;9:172-182
Percutaneous Endoscopic Gastrostomy:
Advantages
The same as for surgical gastrostomy
No surgery / less invasive
Minimal sedation
Direct visualization
< 30 minutes to place tube
Lower costs
Percutaneous Endoscopic Gastrostomy:
Placement Criteria
Adequate passage for endoscope
Ease in identifying safe site
Ease in determining a safe tract
Functioning GI tract
Absence of ascites / morbid obesity

Stellato TA, et al. Ann Surg 1984;200:46-50
Lee M, et al. Clin Radiol 1991;44:332-334
Surgical Gastrostomy
Performed in operating room
Indicated when PEG is contraindicated or during other
surgical procedures
Requires general anesthesia and full surgical team
In observation during recovery
More expensive than PEG

Surgical Gastrotomy
Jejunostomy
Gastrostomy: Low-Profile Tube

Post-pyloric Access
Indications for post-pyloric route
Patient at risk for bronchial aspiration, gastric reflux
Gastric feeding contraindicated
Gastric motility disorders; e.g., gastroparesis
Upper GI tract condition; e.g., carcinoma,
stricture, fistula

Post-pyloric Access

Montecalvo MA, et al. Crit Care Med 1992;20:1377-1387
Advantages

Allows earlier post-op
feeding
Lower risk of
aspiration
Disadvantages

Small bore tubes, prone to
obstruction
Tubes can be dislodged into
stomach
Difficult to maintain long term
Potential for dumping syndrome
Requires infusion pump

Post-pyloric Feeding Techniques

Gauderer MW, et al. J Pediatr Surg 1980;15:872-875
Short Term

Nasoenteric
Nasoduodenal
Nasojejunal
Long Term

Jejunostomy
Percutaneous endoscopic
jejunostomy or through the
PEG tube
Surgical jejunostomy

Nasal Access: Tubes

Nasogastric Nasoduodenal / Jejunal
Easy
Short term
Y-Port
Small bore
Weighted tip
Metal guidewire
Post-pyloric Enteral Nutrition:
Indications
History / risk of reflux or aspiration
Gastric motility disorders
Upper GI tract fistulae
Acute pancreatitis

Post-pyloric Enteral Nutrition:
Advantages
Easily accessible
Less invasive
Lower risk of aspiration
Manual, fluoroscopic, or endoscopic placement
Post-pyloric Enteral Nutrition:
Disadvantages
Placement can be difficult to achieve and maintain
Requires x-ray confirmation
Short term use only
Nasopharyngeal trauma / irritation
Small bore tube

Jejunostomy Feeding: Indications

Feeding
contraindicated for
upper GI tract
Gastric motility
disorders
History / risk of reflux
or aspiration
Nutrition by Jejunostomy:
Disadvantages
Small bore tube
Placement can be difficult to achieve and maintain
Difficult to maintain for long term
Percutaneous Endoscopic Jejunostomy
Tube placed with or without existing PEG
Requires endoscopy
Placed distal to Ligament of Treitz
Bumpers HL, et al. Surg Endosc 1994;8:121-123
Nasal Access: Multilumen Tubes
ENTERAL FORMULAS
n Factors that influence the choice of enteral
formula:
1. Functional status of the GI tract,
2. The extent of organ dysfunction (e.g., renal,
pulmonary, hepatic, or gastrointestinal)
3. The nutrients needed to restore optimal
function and healing
4. The cost of specific products

Low-Residue Isotonic Formulas
n This low-osmolarity compositions
n Provide a caloric density of 1.0 kcal/mL and need
1500-1800 mL to meet daily requirements
Provide baseline carbohydrates, protein,
electrolytes, water, fat, and fat-soluble vitamins
(some do not have vitamin K)
Standard or first-line formulas for stable patients
with an intact gastrointestinal tract

Isotonic Formulas with Fiber
Contain soluble and insoluble fiber, which is most
often soy based
Fiber-based solutions delay intestinal transit time and
reduce the incidence of diarrhea
Fiber stimulates pancreatic lipase activity and is
degraded by gut bacteria into short-chain fatty acids
(as fuel for colonocytes)
No contraindications for using fiber-containing
formulas in critically ill patients

Immune-Enhancing Formulas
Fortified with special nutrients to enhance
immune or solid organ function
Including glutamine, arginine, branched-chain
amino acids, omega-3 fatty acids, nucleotides,
and beta carotene
The addition of amino acids to these formulas
generally doubles the amount of protein
(nitrogen) found in standard formula; however,
their cost can be prohibitive

Calorie-Dense Formulas
n Have greater caloric value for the same
volume
n Provide 1.5 to 2 kcal/mL suitable for
patients requiring fluid restriction or
those unable to tolerate large-volume
infusions
High-Protein Formulas
n Available in isotonic and nonisotonic
mixtures
n Proposed for critically ill or trauma
patients
n Nonprotein-calorie:nitrogen ratios
between 80:1 and 120:1.

Elemental Formulas
Advantage ease of absorption
n Not indicated for long term use as a primary source
of nutrients because of the inherent scarcity of fat,
associated vitamins, and trace elements
n High osmolarity, dilution or slow infusion rates
n Used frequently in patients with malabsorption, gut
impairment, and pancreatitis
n Higher cost than standard formulas.

Renal-Failure Formulas
n Benefits lower fluid volume and
concentrations of K, P, and Mg needed to
meet daily calorie requirements
n Contains essential amino acids
n Has high nonprotein-calorie:nitrogen
ratio
n Not contain trace elements or vitamins
Pulmonary-Failure Formula
n Increased fat content to 50% of the total
calories and reduction in carbohydrate
content
n Goal to reduce carbon dioxide
production and alleviate ventilation
burden for failing lungs

Hepatic-Failure Formulas
50% of the proteins are branched-chain amino
acids (e.g., leucine, isoleucine, and valine)
Goalreduce aromatic amino acid levels and
increase the levels of branched-chain amino
acids to reverse encephalopathy
Protein restriction should be avoided because
patients have significant protein energy
malnutrition predisposition of additional
morbidity and mortality
MONITORING
PARAMETER DURING
INITIATION
STABLE ACUTE
PATIENT
LONG TERM
PATIENT
Blood chemistry 2 - 3 times/week Every 1 - 2 weeks Every 6 months
Lytes, BUN,
Creatinine
Daily 2 - 3 times/week Every 6 months
Triglycerides Weekly Every 1 - 2 weeks Every 6 months
Glucose 2 - 3 times/week Every 1 - 2 weeks Every 6 months
Serum proteins Weekly Monthly Every 6 months
Weight Daily 2 - 3 times/week Weekly
I & O Daily 2 - 3 times/week Weekly
Nitrogen balance PRN PRN PRN
COMPLICATIONS
n Tube feeding diarrhea, aspiration, vomiting,
distension, metabolic abnormalities, and tube
dislodgment
n Aspiration minimized by elevation of the
head 30, use prokinetic agents, feedings
beyond the ligament of Treitz
n Abdominal distention and cramps corrected
by temporarily discontinuing feedings and
resuming at a lower infusion rate

COMPLICATIONS
n Diarrhea usually is not caused by the tube
feedings but by other therapies
n Caused by use of medications via the tube
(sorbitol, antibiotics, prokinetic agents,
magnesium antacids) reversed by
discontinuation of these medications
n Reduce diarrhea by fiber-containing diet to
provide substrate for the colonocytes
n Metabolic Complications
PROBLEM CAUSE TREATMENT
Hyponatremia Overhydration Change formula
Restrict fluids
Hypernatremia Inadequate fluid intake Increase free water
Dehydration Diarrhea
Inadequate fluid intake
Evaluate causes of diarrhea
Increase free water
Hyperglycemia Too many calories
Lack of adequate insulin
Evaluate caloric intake
Adjust insulin
Hypokalemia Refeeding syndrome
Diarrhea
Replace K
Evaluate causes of diarrhea
Hyperkalemia Excess K intake
Renal insufficiency
Change formula
COMPLICATIONS
n Jejunal tube feedings pneumatosis intestinalis
and small-bowel necrosis
n Pathophysiology: bowel distention and consequent
reduction in bowel wall perfusion (inadequate
splanchnic perfusion)
n Factors: hyperosmolarity of solutions, bacterial
overgrowth, fermentation, and accumulation of
metabolic breakdown products
Enteral feedings in the critically ill patient should
be delayed until adequate resuscitation has been
achieved


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