ENTERAL NUTRITION

Tim Dosen
Departemen Farmasi Klinis
Program Studi
Sarjana Farmasi
FKUB
 Definition

the delivery of nutrients

(macronutrients, micronutrients,
calori
mouth tube

to provide calories, macronutri-

ents, and micronutrients to those
patients who are unable to
achieve these requirements from
an oral diet
Conditions That Require Specialized Nutrition Support

Enteral Parenteral

Impaired ingestion Gastrointestinal incompetency

Hypermetabolic state with

Inability to consume adequate
poor enteral tolerance or
nutrition orally
accessibility

Impaired digestion,
absorption, metabolism

Severe wasting or depressed

growth
Nutrition
Therapy
Algorithm
 Indications of Enteral Nutrition

Malnourished patient expected to be unable to eat >5-7 days

Normally nourished patient expected to be unable to eat

>7-9 days

Adaptive phase of short bowel syndrome

Increased needs that cannot be met through oral intake

(burns, trauma)

Inadequate oral intake resulting in deterioration of nutritional

status or delayed recovery from illness
Indications of Enteral Nutrition
 Contraindications of Enteral Nutrition

High
Severe
acute
output Inability to gain
pancreatitis proximal access
fistula

Inadequate
Intractable Aggressive resuscitation
or
vomiting or therapy not hypotension;
diarrhea warranted hemodynamic
instability

Intestinal
Ileus obstruction

Expected need
less than 5-7 days Severe
if malnourished or G.I.
7-9 days if normally Bleeding
nourished
 Enteral Formulas
uid diets intended
Ready-to-use or
oral use or for tube
ding powdered form

igned to meet
Can be used alone
ety of medical and
ition needs or given with foods
 Formula Selection

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
 Enteral Formula Categories

Polymeric

Monomeric

Fiber containing

Calori dense

Rehydration

Disease spesific
 Polymeric
• Whole protein nitrogen
source
• For use in patients with
normal or near normal GI
function
– Protein isolate formulas
– Protein that has been
separated from a food
(casein from milk,
albumin from egg)
– Blenderized formulas
• May contain pureed meat,
vegetables, fruits, milk,
starches
• Made at home or purchased
commercially
Monomeric

MCT: medium chain triglycerides; LCT: long chain triglycerides

 Fiber Containing

containing a source of fiber; reportedly beneficial for

prevention/treatment of altered bowel function in enterally
fed patients

Soy polysaccharide is the most common fiber

additive in enteral feedings; effectiveness in treating
diarrhea in tubefed patients unproven

Soluble fiber (guar gum, oat fiber, pectin) may exert

trophic effect on colonic mucosa and be useful in
normalizing bowel function

Most enteral feedings in amounts typically used

contain less than recommended fiber intake for
adults (20-35 g)

Patients with impaired gastric emptying should not be fed

fiber-containing formula into the stomach
 Calorie Dense

May be used in Useful for

nocturnal
fluid-restricted
feedings where
or volume-
nutrition must be
sensitive delivered over
patients brief time span

Calorie
density Monitor
ranges from fluid/hydrati
1.3 to 2 on status
kcals/ml
 Enteral Formula Categories
Disease Specific

Pharmaceutical
Designed for patients effects are claimed Pharmaceutical
with specific disease
states (respiratory
for many specialty prices (8-10
enteral formulas
disease, ARDS,
(reduced LOS/length times more
diabetes, renal failure,
hepatic failure, and of stay, reduced expensive than
immune compromise) infections, reduced standard)
time on the ventilator)

ARDS: acute respiratory

distress syndrome
 Disease Specific Formulas Diabetic

• Blood glucose control in

acute care is often affected
by illness, infection, other
issues
• Patients on enteral
feedings generally receive
a more consistent CHO
intake than persons on oral
diets
• May be worth trying
diabetes formulas in
patients who have failed to
achieve good blood
glucose control on standard
formulas
 Disease Specific Formulas Hepatic

• Generally have reduced aromatic amino

acids and increased branched chain amino
acids
• More expensive than standard products
• Often lower in protein than standard
formulas (may be too low for most liver
patients)
• Research using these products has been
inconclusive
• Standard (high protein) products are
generally appropriate for patients with liver
disease
 Disease Specific Formulas Renal

• Originally developed in an
effort to delay the need for
dialysis as long as possible
• Typically are calorie dense
(2.0 kcal/cc) products with
relatively low protein levels
and modified electrolytes
• Generally too low in protein
for dialyzed patients and
acutely ill patients
• May be useful for short term
use as supplement or
calorie source in pre-
dialysis chronic renal failure
patients
Enteral Access
Selection of Enteral Access
 Administration Methods

• Preferred method in critically ill patients

Continuous • EN infusion rates generally range from 50 to 125 mL/h (adults); 1 to 2
mL/kg per hour (children) abdominal distension, vomiting, and diarrhea

Cyclic
• Complaints of fullness and lack of appetite infused only at night
may be particularly useful for the home patient or patient
requiring rehabilitation

Bolus
Intolerance to bolus administration over 5 to 10 min  20-60 min

Intermittent may be helpful to administer the prescribed volume over a longer

time period
 Regimen Therapy

Initiated at
Isotonic (300
rates of 50
cc/hr in adults mOsm/L)

The rate of administration To calculate goal rates

can usually be advanced
based on 20-22
in 20-25 cc/hr increments
every 8 hours until goal
hours/day allowing for
rate is achieved interruptions in delivery.
 Fluids Requirement

A healthy adult ingests approximately 1 mL free water/kcal of

energy, or 35-50 mL/kg body weight/day

Hospitalized patients usually require 30-35 mL/kg/day. Fluid needs

may also be approximated as 1500 mL per m2BSA

Patients with liver disease, renal failure, cardiac or pulmonary diseases or closed head injuries may require restricted fluid intakes while patients with
nasogastric output, diarrhea, hypovolemia secondary to burns or trauma, diuresis, fistulae, and insensible losses may require additional fluids
 Proteins
Average patient receiving nutritional intervention
requires 0.8 - 2.0 g protein/kg usual body weight

Estimating Protein Requirements

Clinical Status Protein Requirements (g/kg/day)*

Maintenance 0.8-1.0
Mild to Moderate Depletion 1.0-1.5
Post-operative 1.2-2.0

*Note: Table based on usual body weight except in obese patients

 Electrolyte
Typical Adult Baseline Electrolyte Requirements During Nutritional Repletion
Electrolyte Daily Requirements Comments
sodium (chloride, acetate, 60-150 mEq basal catabolism: 1-4
or phosphate) mEq/kg mild-moderate
catabolism: 2-3 mEq/kg
severe catabolism: 3-4
mEq/kg
potassium (chloride, 70-150 mEq basal catabolism: 0.7-0.9
acetate, or phosphate) mEq/kg mild-moderate
catabolism: 2 mEq/kg severe
catabolism: 3-4 mEq/kg

chloride (sodium or 60-150 mEq replaced 1 mEq per 1 mEq

potassium) Na or K unless other salt
form specified
magnesium (sulfate) 8-24 mEq monitor serum Mg
concentration
phosphate (sodium or 7-10 mMol per 1000 kcal severe catabolism or
potassium) prolonged absence of
nutritional intake: 15-25
mMol per 1000 kcal of
glucose
 Energy

• Calculate Basal Energy Expenditure (BEE).

BEE refers to the metabolic activity necessary to sustain
life (i.e., respiration, pulse, body temperature) and can be
estimated using the following equation: Harris-Benedict
equation:

• BEE (kcal/day):
Males = 66.5 + (13.7 X W) + (5.0 X H) - (6.8 X A)
Females = 655 + (9.6 X W ) + (1.7 X H) - (4.7 X A)
where: W = usual or adjusted weight in kilograms
H = height in centimeters
A = age in years
 BEE Correction Factors for
Physical Activity and Clinical Status*
Physical Activity Factor Clinical Status Factor
strict bedrest 1.2 fever 1.0 + 0.13/°C
out of bed 1.3 elective surgery 1.0-1.1
shivering/thrashing
1.3 peritonitis 1.2-1.5
(menggigil)

quadriparesis 0.8 soft tissue trauma 1.1-1.4

paralysis 0.9 multiple fractures 1.2-1.4

hemiparesis 1.2-1.3 closed head injury 1.5-1.8

severe
    1.4-1.8
infection/sepsis
    cancer 1.1-1.3
    COPD 1.2-1.3
    major burns 1.5-2.0
    AIDS 1.5-1.8
Calculate Total Energy Expenditure (TEE)

By multiplying the Select the

BEE by a factor factor that
that accounts for
corresponds to
physical activity
and clinical status the patient's
(Only one factor dominant
should be used) situation

Require 1.3 - Adjusted as

1.7 times the illness progresses
and recovery
BEE in total
proceeds to avoid
caloric intake complications of
or between 30 under or over
and 35 kcal/kg feeding
 Fat

A higher percent fat intake

may be desired for
Current national patients with poor
appetites/limited food
guidelines intake to increase caloric
recommend density of foods (fat
contains 9 kcal/g vs. 4
limiting fat intake kcal/g in carbohydrates
and protein). A minimum of
to less than 30% 2-4% kcals as linoleic acid
of total kcals is required daily to prevent
essential fatty acid
deficiency
 Calorie Need for Adult Critical Illness Patient

INITIAL
%AGE OF
NUTRIENT QUANTITY REQUIREMENT
TOTAL
FOR 60 Kg
CALORIES
ADULT

Total calories 25 Kcal/kg/day 100% 1500 Kcal/day

Proteins, peptides
60-70 g/day
and amino 1-1.75 g/kg/day 15-25%
240-280 kcal/day
acids
190g/day
Carbohydrates 3-3.5 g/kg/day 40-60% 760kcal/day

Fats 0.75-1 g/kg/day 20-30% 50g/day

450kcal/day
 Micronutrients

• isoleucine, leucine, lysine, methionine, phenylalanine,

Amino acids threonine, tryptophan, valine, histidine

Fatty acids • linoleic acid, linolenic acid

• Fat soluble - retinol (A), 25-hydroxycholecalciferol (D), a-tocopherol (E), phylloquinone

Vitamins •
(vitamin K)
Water soluble - thiamin (B1), riboflavin (B2), pyridoxin (B6), niacin (B3), folic acid,
cobalamin (B12), biotin, panthothenic acid (B5), ascorbic acid (C)

• calcium, chloride, magnesium, phosphate,

Minerals potassium, sodium
 Complications of Enteral Nutrition

• Hydration
Metabolic • Electrolyte imbalance
Complications • Altered glucose control

• Associated with tube feeding include nausea,

Gastrointestina vomiting, abdominal distension, cramping,
l Complications aspiration, diarrhea, and constipation

• Those associated with the feeding tube,

Mechanical including tube occlusion or malposition, and
Complications nasopulmonary intubation
 Medications and Enteral Nutrition

M
e
d
i
c
a
t
i
o
n
s

s
h
o
u
l
d

n
e
v
e
r

b
e

a
d
d
e
d

d
i
r
e
c
t
l
y

t
o

t
h
e

f
e
e
d
i
n
g

f
o
r
m
u
l
a
t
i
o
n
Interaction
 Nutrition Outcome Goals

To To
promote To reduce
promote
growthdisease-
an
and related
adequate
developmemorbidity
nutritional
nt of and
state ininfants &
mortality
adults children
SELAMAT BELAJAR
SEMOGA SUKSES SELALU