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Chapter 23

Enteral and
Parenteral
Nutrition Support

Enteral Nutrition Definition

Nutritional support via placement through
the nose, esophagus, stomach, or intestines
(duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first.

© 2004, 2002 Elsevier Inc. All rights reserved.

Oral Supplements

Between meals

Added to foods

Added into liquids for medication pass
by nursing

Enhances otherwise poor intake

May be needed by children or teens to
support growth

© 2004, 2002 Elsevier Inc. All rights reserved.

absorption.Conditions That Require Other Nutrition Support  Enteral —Impaired ingestion —Inability to consume adequate nutrition orally —Impaired digestion. . metabolism —Severe wasting or depressed growth  Parenteral —Gastrointestinal incompetency —Hypermetabolic state with poor enteral tolerance or accessibility © 2004. 2002 Elsevier Inc. All rights reserved.

All rights reserved. 2002 Elsevier Inc.Conditions That Often Require Nutritional Support © 2004. .

Conditions That Often Require Nutritional Support –cont’d © 2004. 2002 Elsevier Inc. . All rights reserved.

2002 Elsevier Inc.Conditions That Often Require Nutritional Support –cont’d © 2004. . All rights reserved.

Algorithm for Decisions

Modified and adapted from Gorman RC, Morris JB: Minimally invasive access to the gastrointestinal tract. In Rombeau JL,
Rolandelli RH, editors: Clinical nutrition: enteral and tube feeding, p 174, Philadelphia, 1997, WB Saunders; and Ali A et al:
Nutritional support services, Nutritional Support Algorithms, 8(7):13, July 1998.

© 2004, 2002 Elsevier Inc. All rights reserved.

Considerations in Enteral Nutrition
1.

Applicable

2.

Site placement

3.

Formula selection

4.

Nutritional/medical requirements

5.

Rate and method of delivery

6.

Tolerance

© 2004, 2002 Elsevier Inc. All rights reserved.

Formula Selection
The suitability of a feeding formula should be
evaluated based on
 Functional status of GI tract

Physical characteristics of formula (osmolality,
fiber content, caloric density, viscosity)

Macronutrient ratios

Digestion and absorption capability of patient

Specific metabolic needs

Contribution of the feeding to fluid and electrolyte
needs or restriction

Cost effectiveness

© 2004, 2002 Elsevier Inc. All rights reserved.

All rights reserved.Enteral Formula Categories © 2004. . 2002 Elsevier Inc.

.Factors to Consider When Choosing an Enteral Formula © 2004. All rights reserved. 2002 Elsevier Inc.

2002 Elsevier Inc.Enteral Access: Clinical Considerations  Duration of tube feeding —Nasogastric or nasoenteric tube for short term —Gastrostomy and jejunostomy tubes for long term  Placement of tube —Gastric —Small bowel © 2004. All rights reserved. .

2002 Elsevier Inc. All rights reserved.Placement Site  Access (medical status)  Location (radiographic confirmation)  Duration  Tube measurements and durability  Adequacy of GI functioning © 2004. .

. All rights reserved.Enteral Tube Placement © 2004. 2002 Elsevier Inc.

2002 Elsevier Inc. . All rights reserved.Advantages—Enteral Nutrition  Intake easily/accurately monitored  Provides nutrition when oral is not possible or adequate  Costs less than parenteral nutrition  Supplies readily available  Reduces risks associated with disease state © 2004.

2002 Elsevier Inc.More Advantages— Enteral Nutrition  Preserves gut integrity  Decreases likelihood of bacterial translocation  Preserves immunologic function of gut  Increased compliance with intake © 2004. All rights reserved. .

. 2002 Elsevier Inc. monitoring © 2004. metabolic. increased risk of bacterial contamination.Disadvantages—Enteral Nutrition  GI. pneumothorax  Costs more than oral diets  Less “palatable/normal”  Labor-intensive assessment. All rights reserved. and mechanical complications —tube migration. administration. tube obstruction. tube patency and site care.

2002 Elsevier Inc.Complications of Enteral Feeding  Access problems (tube obstruction)  Administration problems (aspiration)  Gastrointestinal complications (diarrhea)  Metabolic complications (overhydration) © 2004. . All rights reserved.

Aspiration Pneumonia  Can result from enteral feeds  High-risk patients —Poor gag reflex —Depressed mental status © 2004. 2002 Elsevier Inc. All rights reserved. .

2002 Elsevier Inc. .Reducing Risk of Aspiration  Check gastric residuals if receiving gastric feeds  Elevate head of the bed >30 degrees during feedings  Postpyloric feeding —Nasoenteric tube placement may require fluoroscopic visualization or endoscopic guidance —Transgastric jejunostomy tube © 2004. All rights reserved.

Rate and Method of Delivery*  Bolus—300 to 400 ml rapid delivery via syringe several times daily  Intermittent─300 to 400 ml. . feeding route and volume. All rights reserved. and nutritional goals © 2004. 20 to 30 minutes. several times/day via gravity drip or syringe  Cyclic—via pump usually at night  Continuous—via gravity drip or infusion pump *Determined by medical status. 2002 Elsevier Inc.

2002 Elsevier Inc. sodium or calcium casein. . lactalbumin —Hydrolyzed (more particles)—peptides or free amino acids © 2004. All rights reserved.Consideration of Physical Properties of Enteral Formulas  Residue  Viscosity —Size of tube is important  Osmolality: consider protein source —Intact (do not affect osmolality)—soy isolates.

2002 Elsevier Inc.Renal Solute Load  Normal adult tolerance is 1200 to 1400 mOsm/L  Infants and renal patients may tolerate less © 2004. All rights reserved. .

All rights reserved. 2002 Elsevier Inc.Lower Osmolality  Large (intact) proteins  Large starch molecules © 2004. .

All rights reserved. .Higher Osmolality  Hydrolyzed protein or amino acids  Disaccharides © 2004. 2002 Elsevier Inc.

All rights reserved. diarrhea —Constipation. cramps —Aspiration —Abdominal distention © 2004.Tolerance  Signs and symptoms: —Consciousness —Respiratory distress —Nausea. 2002 Elsevier Inc. vomiting. .

2002 Elsevier Inc. .Tolerance—cont’d  Other signs and symptoms —Hydration —Labs —Weight change —Esophageal reflux —Lactose/gluten intolerances —Glucose fluctuations © 2004. All rights reserved.

.6 kcal 30.65 g protein © 2004.153 % protein x 200 kcal = 30. 2002 Elsevier Inc.6 kcal x 1g protein/4 kcal = 7.3% protein product that has 1 kcal/ml 1 kcal/ml x 200 ml = 200 kcal 0.How to Determine Energy and Protein kcal/ml x ml given = kcal % protein x kcal = kcal as protein kcal as protein x 1 g/4 kcal = g protein Example: Patient drinks 200 cc of a 15. All rights reserved.

All rights reserved. .2 kcal/ml = usual concentration 2 kcal/ml = highest concentration © 2004. 2002 Elsevier Inc.Energy in Formulas 1 to 1.

.Protein  From 4% to 26% of kcal is possible  14% to 16% of kcal is usual  18% to 26% of kcal—considered to be high-protein solution © 2004. 2002 Elsevier Inc. All rights reserved.

or consider 35 ml/kg if history of dehydration © 2004. or cardiac failure.5 ml/kcal or 150 ml/kg  Normal tube feeding: 1 kcal/ml. 80% to 85% water  Elderly: consider 25 ml/kg with renal. .Recommended Water  Healthy adult: 1 ml/kcal or 35 ml/kg  Healthy infant: 1. liver. 2002 Elsevier Inc. All rights reserved.

All rights reserved. nurse will flush tube with water about 3 times daily—include this amount in estimated needs —Example: “flush with 200 cc tid” © 2004.Sources of Fluid (“Free Water”)  Liquids  Water in food  Water from metabolism  With tube feeding. 2002 Elsevier Inc. .

All rights reserved. .Administration: Feeding Rate  Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hours  Intermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hours  Bolus method = may give 300 to 400 ml several time a day (“push” is not desired) © 2004. 2002 Elsevier Inc.

French Units—Tube Size  Diameter of feeding tube is measured in French units  1F = 33 mm diameter  Feeding tube sizes differ for formula types and administration techniques. 2002 Elsevier Inc. © 2004. All rights reserved. .

2002 Elsevier Inc. All rights reserved. .Examples of Special Formulas  Pediatrics  Low residue  High protein  Volume restriction  Diabetic  Pulmonary/COPD © 2004.

2002 Elsevier Inc. . All rights reserved.Enteral Nutrition Monitoring © 2004.

Routes of Parenteral Nutrition  Central access —TPN both long.and short-term placement  Peripheral or PPN —New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis <2000 kcal required or <10 days © 2004. . 2002 Elsevier Inc. All rights reserved.

)  Fluid tolerance  Osmolarity  Duration  Central line contraindicated © 2004.PPN vs. PPN conc. 2002 Elsevier Inc. . TPN  Kcal required (10% dextrose max. All rights reserved.

2002 Elsevier Inc. .Venous Sites from Which the Superior Vena Cava May Be Accessed © 2004. All rights reserved.

. 2002 Elsevier Inc. All rights reserved.Advantages—Parenteral Nutrition  Provides nutrients when less than 2 to 3 feet of small intestine remains  Allows nutrition support when GI intolerance prevents oral or enteral support © 2004.

Indications for Total Parenteral Nutrition  GI non functioning  NPO >5 days  GI fistula  Acute pancreatitis  Short bowel syndrome  Malnutrition with >10% to 15 % weight loss  Nutritional needs not met. All rights reserved. patient refuses food © 2004. 2002 Elsevier Inc. .

2002 Elsevier Inc.Contraindications  GI tract works  Terminally ill  Only needed briefly (<14 days) © 2004. . All rights reserved.

. All rights reserved.Calculating Nutrient Needs  Avoid excess kcal (> 40 kcal/kg)  Adults kcal/kg BW Obese—use desired BMI range or an adjusted factor © 2004. 2002 Elsevier Inc.

38) + IBW © 2004.Adjusted Body Weight Adjusted IBW for obesity Female: ([actual weight – IBW] x 0.32) + IBW Male: ([actual weight – IBW] x 0. All rights reserved. 2002 Elsevier Inc. .

2002 Elsevier Inc.1 kcal/ml 20% emulsions = 2 kcal/ml © 2004.5. 10% solutions  Fat 10% emulsions = 1. . 7. 8.Parenteral Components  Carbohydrate glucose or dextrose monohydrate 3.5. 5. 3. All rights reserved.4 kcal/g  Amino acids 3.

. 2002 Elsevier Inc.5 g protein/kg IBW burns or severe trauma © 2004.2 to 1. All rights reserved.Protein Requirements  1.5 g protein/kg IBW mild or moderate stress  2.

Carbohydrate Requirements  Max. 0. All rights reserved.36 g/kg BW/hr  Excess glucose causes: Increased minute ventilation Increased CO2 production Increased RQ Increased O2 consumption Lipogenesis and liver problems © 2004. . 2002 Elsevier Inc.

. 2002 Elsevier Inc.5 g fat/kg © 2004.Lipid Requirements  4% to 10% kcals given as lipid meets EFA requirements. 60% of kcal or 2. or 2% to 4% kcals given as lineoleic acid  Usual range 25% to 35% max. All rights reserved.

2002 Elsevier Inc. .Other Requirements  Fluid—30 to 50 ml/kg  Electrolytes Use acetate or chloride forms to manage acidosis or alkalosis  Vitamins  Trace elements © 2004. All rights reserved.

2002 Elsevier Inc. Fat is isotonic and does not contribute to osmolarity. Multiply the grams of protein per liter by 10. Total osmolarity = 250 + 300 = 500 mOsm/L © 2004. 4. Example: 30 g of protein x 10 = 300 mOsm/L 3. .Calculating the Osmolarity of a Parenteral Nutrition Solution 1. Example: 50 g of dextrose x 5 = 250 mOsm/L 2. Multiply the grams of dextrose per liter by 5. Electrolytes further add to osmolarity. All rights reserved.

additives  3-in-1 solution of lipid. All rights reserved. amino acids. glucose. glucose. .Compounding Methods  Total nutrient admixture of amino acids. additives © 2004. 2002 Elsevier Inc.

. All rights reserved.Administration  Start slowly (1 L 1st day. 2002 Elsevier Inc. 2 L 2nd day)  Stop slowly (reduce rate by half every 1 to 2 hrs or switch to dextrose IV)  Cyclic give 12 to 18 hours per day © 2004.

All rights reserved.Monitoring and Complications  Infection  Hemodynamic stability  Catheter care  Refeeding syndrome © 2004. . 2002 Elsevier Inc.

Refeeding Syndrome  Hypophosphatemia  Hyperglycemia  Fluid retention  Cardiac arrest © 2004. 2002 Elsevier Inc. All rights reserved. .

All rights reserved. Cl-) Glucose Acid-base status 3 times/week BUN Ca+.Monitor  Weight (daily)  Blood Daily Electrolytes (Na+. K+. P Plasma transaminases © 2004. . 2002 Elsevier Inc.

All rights reserved.Monitor—cont’d  Blood Twice/week Ammonia Mg Plasma transaminases Weekly Hgb Prothrombin time Zn Cu Triglycerides © 2004. 2002 Elsevier Inc. .

2002 Elsevier Inc. .Monitor—cont’d  Urine: Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly)  Other: Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity. temperature. All rights reserved. respiration (daily) WBC and differential (as needed) Cultures (as needed) © 2004.

Catheter sepsis 2. All rights reserved. Metabolic © 2004.Problems  PPN Site irritation  TPN 1. 2002 Elsevier Inc. Placement problems 3. .

2002 Elsevier Inc. All rights reserved. .25 mild stress 1.00 high stress © 2004.Pediatric  Energy Infant 50 to 60 kcal/kg/day maintenance 70 to 120 kcal/kg/day growth  Child >1yr BEE 1to 8 yrs 70 to 100 kcal/kg/day 8 to 12 yrs 60 to 75 kcal/kg/day 12 to 18 yrs 45 to 60 kcal/kg/day Injury factors 1.50 nutritional depletion 2.

4 to 4 g/kg/day <1500 g weight 2.0 to 1.5 to 2.Pediatric—cont’d  Protein: Infant 2.5 g/kg/day 0 to 12 months normal weight  Child >1 year 1 to 8 years 1. All rights reserved.0 to 2.5 g/kg/day © 2004.0 g/kg/day 8 to 15 years 1. 2002 Elsevier Inc. .

Pediatric—cont’d  Carbohydrate Infant preterm: 4 to 6 mg/kg/minute begin rate Term infants: 8 to 9 mg/kg/minute begin rate  Fat Infants: 0. 2002 Elsevier Inc.5 to 1. . All rights reserved.0 g/kg/day min for EFA needs 2 to 3 g/kg/day max  Vitamins and minerals: See tables in textbook © 2004.

2002 Elsevier Inc.Pediatric—cont’d  Fluid and electrolytes Infant: LBW 125 to 150 ml/kg/day 2 to 4 mmol/kg/day for electrolytes  Other infants and children © 2004. . All rights reserved.

Document in Chart  Type of feeding formula and tube  Method (bolus. pump)  Rate and water flush  Intake energy and protein  Tolerance. drip. complications. 2002 Elsevier Inc. and corrective actions  Patient education © 2004. All rights reserved. .