• COURSE NAME: Critical Care & Emergency Nutrition

• COURSE CODE:SHS.514 lec.03

• INSTRUCTOR: Saba Nadeem Dar

School of Health Sciences

University of Management and technology
 Lecture outcomes
• Administration techniques
• Complications of enteral feeding
• Enteral nutrition formulas
Administration techniques
Types of administration techniques
Administration techniques

Bolus feeding Intermittent feeding Continuous Drip

Bolus Feeding
 Bolus feeding
• It may also be called syringe or gravity feeding. 

• Most people take a bolus or a “meal” of formula about every 3

hours or so.
 Bolus feeding

• The feeding modality of choice when patients are clinically

stable with a functional stomach is the syringe bolus method.

• Syringe bolus feedings administered over 5 to 20 minutes

 Bolus feeding

• If bloating or abdominal discomfort develops, the patient is

encouraged to wait l0 to 15 minutes before proceeding with
the remainder of formula allocated for that feeding.
 Bolus feeding

• Formula at room temperature may be better tolerated than

cold formula.

• Follow label directions for storing partially used cans of

formula.
 Video link
• https://www.youtube.com/watch?v=CandLfoWUwk

• https://www.youtube.com/watch?v=8DCVRyjJD7Y
 Intermittent Drip

• These feedings can be given by pump or gravity drip.

• A schedule is based on four to six feedings per day

administered for 20 to 60 minutes.
Intermittent Drip
 Intermittent Drip

• Formula administration is initiated at 100 to 150 ml per feeding

and increased incrementally as tolerated

• Success with this method of feeding depends largely on the

degree of mobility, alertness, and motivation of the patient to
tolerate the regimen
 Continuous Drip
• Continuous drip infusion of formula requires a pump.

• This method is appropriate for patients who do not tolerate large-volume

infusions during a given feeding.

• Patients with compromised gastrointestinal function because of disease are

candidates for continuous drip infusion.
 Continuous Drip

• The feeding rate goal, in milliliters per hour, is set by dividing

the total daily volume by the number of hours per day of
administration (usually 18 to 24 hours).
 Complications

• Abdominal leakage of gastric contents from a gastrostomy site

can cause skin erosion and skin breakdown, leading to
infection and peritonitis.
• Aspiration is a concern for patients receiving enteral nutrition

• To minimize the risk of aspiration, patients should be

positioned with their heads and shoulders above their chest
during and immediately after feeding.
• In critically ill patients the best methods for decreasing the risk
of aspiration are elevating the head of the bed.
• Monitoring of gastric residuals may be helpful in identifying
delayed gastric emptying and increased risk of aspiration.
• Blue dye added to enteral formulas has been used to detect
aspiration of formula for years.

• Reports indicate that some critically ill patients have discoloration

of the skin, urine, serum or other body fluids after ingestion of the
blue dye and that some have died within days of dye ingestion.
Diarrhea

Reasons of diarrhea

• Bacterial overgrowth

• Antibiotic therapy

• Gastrointestinal motility disorders

• Hyperosmolar medications such as magnesium-containing antacids, sorbitol-

containing elixirs, and electrolyte supplements can also contribute to diarrhea
• The addition of soy polysaccharide, a prebiotic, pectin, and
other fibers, bulking agents ,probiotics, and antidiarrheal
medications can also be beneficial.
Constipation

• Fiber-containing formulas or stool-bulking medications may be

helpful, and adequate fluid must be provide
 Complications of Enteral Nutrition
• Access

– Leakage from stoma site

– Pressure necrosis/ulceration
– Tissue erosion
– Tube displacement/migration
– Tube obstruction/occlusion
 Complications of Enteral Nutrition
• Administration

– Microbial contamination
– Enteral misconnections or misplacement of tube, causing infection,
aspiration pneumonia, peritonitis, pulmonary or venous infusion
– Regurgitation
 Complications of Enteral Nutrition
• Gastrointestinal
– Constipation
– Delayed gastric emptying
– Diarrhea
Osmotic diarrhea, especially if sorbitol is present in liquid drug preparations
– Distention/bloating/cramping
– Intolerance of nutrient components
– Maldigestion/malabsorption
– Nausea/vomiting
 Complications of Enteral Nutrition
• Metabolic
– Drug-nutrient interactions
– Glucose intolerance/hyperglycemia/hypoglycemia
– Dehydration/overhydration
– Hypernatremia/hyponatremia
– Hyperkalemia/hypokalemia
– Hyperphosphatemia/hypophosphatemia
– Micronutrient deficiencies (notably thiamin)
– Refeeding syndrome
 Monitoring

• Abdominal distention and discomfort

• Confirm proper tube placement and maintain head of bed "30
degrees (daily)
• Change feeding delivery container and tubing (daily)

• Fluid intake and output (daily)

• Signs and symptoms of edema or dehydration (daily)
• Stool frequency, volume, and consistency (daily)
• Weight (at least three times/wk)
• Nutritional intake adequacy (daily)
• Clinical status/physical examination (daily)
• Serum electrolytes, blood urea nitrogen, creatinine, (daily till stable, then 2 to 3
times/wk)
• Serum glucose, calcium, magnesium, phosphorus (daily till stable, then weekly)
• Mechanical complications of EN?
• How to manage aspiration?
Thank you!