TUBE FEEDING

Enteral tube nutrition is indicated for patients

who have a functioning GI tract but cannot
ingest enough nutrients orally because they
are unable or unwilling to take oral feedings.
Specific indications for enteral nutrition include the
following:


Prolonged anorexia

Severe protein-energy undernutrition

Coma or depressed sensorium

Liver failure

Inability to take oral feedings due to
head or neck trauma or neurologic
disorders

Critical illnesses (eg, burns) causing
metabolic stress
 Feeding tubes are surgically placed if
endoscopic and radiologic placement is
unavailable, technically impossible, or unsafe
(eg, because of overlying bowel). Open or
laparoscopic techniques can be used.
 Formulas:

Liquid formulas commonly used include

feeding modules and polymeric or other
specialized formulas.
 Feeding modules

are commercially available products that

contain a single nutrient, such as proteins,
fats, or carbohydrates. Feeding modules may
be used individually to treat a specific
deficiency or combined with other formulas
to completely satisfy nutritional
requirements.
 Polymeric formulas
(including blenderized food and milk-based or
lactose-free commercial formulas) are
commercially available and generally provide
a complete, balanced diet. For oral or tube
feedings, they are usually preferred to
feeding modules. In hospitalized patients,
lactose-free formulas are the most
commonly used polymeric formulas.
However, milk-based formulas tend to taste
better than lactose-free formulas. Patients
with lactose intolerance may be able to
tolerate milk-based formulas given slowly by
continuous infusion.
 Specialized formulas
include hydrolyzed protein or sometimes
amino acid formulas, which are used for
patients who have difficulty digesting
complex proteins. However, these formulas
are expensive and usually unnecessary. Most
patients with pancreatic insufficiency, if
given enzymes, and most patients with
malabsorption can digest complex proteins.
Other specialized formulas (eg, calorie and
protein-dense formulas for patients whose
fluids are restricted, fiber-enriched formulas
for constipated patients) may be helpful.
 Administration:

Patients should be sitting upright at 30 to 45°

during tube feeding and for 1 to 2 h
afterward to minimize incidence of
nosocomial aspiration pneumonia and to
allow gravity to help propel the food. Tube
feedings are given in boluses several times a
day or by continuous infusion. Bolus feeding
is more physiologic and may be preferred for
patients with diabetes. Continuous infusion
is necessary if boluses cause nausea.
For bolus feeding, total daily volume is divided
into 4 to 6 separate feedings, which are
injected through the tube with a syringe or
infused by gravity from an elevated bag.
After feedings, the tube is flushed with water
to prevent clogging.
Nasogastric or nasoduodenal tube feeding
often causes diarrhea initially; thus, feedings
are usually started with small amounts of
dilute preparations and increased as
tolerated. Most formulas contain 0.5, 1, or 2
kcal/mL. Formulas with higher caloric
concentration (less water per calorie) may
cause decreased gastric emptying and thus
higher gastric residuals than when more
dilute formulas with the same number of
calories are used.
Initially, a 1-kcal/mL commercially prepared
solution may be given undiluted at 50 mL/h
or, if patients have not been fed for a while,
at 25 mL/h. Usually, these solutions do not
supply enough water, particularly if
vomiting, diarrhea, sweating, or fever has
increased water loss. Extra water is supplied
as boluses via the feeding tube or IV. After a
few days, the rate or concentration can be
increased as needed to meet caloric and
water needs.