AHND 3423 ADVANCE MEDICAL

NUTRITION THERAPY
NUTRITION SUPPORT &
PALLIATIVE CARE 1:
ENTERAL NUTRITION
WA N FAT H I N FA R I Z A WA N M A H M O O D , P H D
D E P T. O F N U T R I T I O N S C I E N C E S
K U L L I Y YA H O F A L L I E D H E A LT H S C I E N C E S
 CONTENTS
PART 1: PART 2: PART 3:
INTRODUCTION TO NUTRITION INITIATION OF
NUTRITION SUPPORT FOR FEEDING
SUPPORT CRITICALLY ILL

1.Enteral Nutrition 1.Enteral Products 1. Initiation of

Support - Types of Enteral Feeding
- Indication & products - Initiation of feeding
contraindication of EN - Indication in adults, children,
- Advantages & peadiatric
disadvantages of EN - Patients positioning
- Route of EN - Flushes method
Administration - Medication
- Methods of Delivery administration
INTRODUCTION TO NUTRITION
SUPPORT
NUTRITION SUPPORT
ESPEN terminology: Nutrition support aim for increased intake of
macro and/or micronutrients. Different from “special diets” eg.
Diabetic diet.
EN refers to – introduction of a nutritionally complete liquid formula
directly into stomach/small intestine via tube.
Different ways to provide nutrition support:
• Oral
• Enteral
• Parenteral
• Combined
 WHEN THE GUT
WORKS – USE IT!
SIGNS OF FUNCTIONING GIT

• The present of bowel sound

• Soft, non-tender abdomen
• Passage of stool
• Intact appetite
GOALS OF NUTRITIONAL
SUPPORT
• Preserve lean body mass (protein)
• Increase protein synthesis
• Improve immune and muscle function
• More rapid recovery
• Shorten hospital stay
• Reduction of morbidity
CONDITION THAT REQUIRES
NUTRITION SUPPORT
• Diminished digestion and absorption
– Pyloric stenosis
– Pancreatic disease
– Biliary disease
– Malabsorption syndrome
– Short bowel syndrome
– Radiation enteritis
– Ulcerative colitis
– Duodenal fistula

• Chronic disease
– Chronic cardiac, hepatic, renal disease
– Malignant disease

• Hypermetabolic conditions
• Changes in metabolic rate and nitrogen excretion with various types of
physiologic stress
<60% intake
 Nutrition care process (NCP)

Individual nutritional status assessment

Identify nutritional diagnosis

Implement appropriate interventions

Monitor & reassess an individual’s response to the nutrition care delivered

Evaluate outcomes-incl. the need for transitional feeding care plan or

termination of nutr. Support intervention

(Lacey & Pritchett, 2003)

ROLES OF NUTRITION SUPPORT TEAM

Doctors

Nurses,
Pharmacists,
Physiotherapies

• Assures optimal nutrition support through implementation of nutrition care

process related to delivery of EN and PN support (Fuhrman et al., 2001)
 ENTERAL
NUTRITION
SUPPORT
WHEN IS EN USED?
• EN should be considered when an individual is:
– not safe for oral intake (e.g. in dysphagia/reduced level of
consciousness)
– when oral intake is not adequate to meet their nutritional
requirements (e.g. when appetite is poor and needs are increased).

• EN - safe, cost effective, and compatible with the body’s

normal processes.
INDICATIONS FOR EN
• Inadequate amount of nutrients and/or calories ingested will
lead to malnutrition - associated with an increased incident of:
– Poor wound healing
– Impaired immune response and response to trauma
– Increased risk of sepsis
– Altered gut structure/function causing malabsorption and spread of bacteria
– Prolong recovery period
– Increased need for nursing care
– Increased risk of serious complications/ infection
– Prolong hospital stay
– Increased medical cost
– Negative impact on QOL
(Middleton et al., 2001; Lazarus & Hamlyn, 2015)
CONTRAINDICATIONS FOR EN
– Obstruction of GIT/bowel
– Severe/protracted ileus
– Major upper GIT haemorrhage
– High-output GIT fistula (>500 ml/day)
– Intractable vomiting or diarrhea
– Inadequate resuscitation or hypotension; hemodynamic
instability
ADVANTAGES - EN
• Preserves gut integrity
• Possibly decreases bacterial translocation
• Preserves immunological function of gut
• Fewer infectious complications in critically ill patients
• Safer and more cost effective in many settings
• Intake easily/accurately monitored
• Provides nutrition when oral is not possible or adequate
• Supplies readily available
• Reduces risks associated with disease state
DISADVANTAGES - EN
• GI, metabolic, and mechanical complications - tube migration;
increased risk of bacterial contamination; tube obstruction;
pneumothorax
• Costs more than oral diets (not necessarily)
• Less “palatable/normal”: patient/family resistance
• Labor-intensive assessment, administration, tube patency and
site care, monitoring
ROUTE OF EN ADMINISTRATION
• Administration of EN should be guided by:
– Patient’s age
– Underlying disease
– Enteral access device
– Condition of GI

• When the patient should be started with EN?

– Early initiation of EN is beneficial if pt. is hemodynamically stable
– In ICU, when EN was initiated within 24-48 hrs. of admission:
• Reduction in mortality
• Lowering incidence of pneumonia & infectious complications
(MNT Critically Ill, 2017)
BY MOUTH (ONS)
• Common sense
– Adequate
– Palatable
– Varied
– Nutritional complete
– Provided at regular intervals, more frequently than regular meal times if necessary
– Progressively increasing in heaviness and complexity

• Cleanliness
– In preparation and serving of food and utensils to prevent GIT infection

• Compassion
– Ensuring the patient ingests the preferred food
– Putting food in patient’s reach
– Conducive eating environment
– Involving dietitians in food selection and preparation
 EN BY TUBE (EN)
• Nutrition provided through the GIT via a tube, catheter, or stoma
that delivers nutrients distal to the oral cavity.

• Benefits of EN:
– Help gut mucosal physiology maintain
– May modulate immune response - prevent translocation of
bacteria and toxins (maintain gut mucosal integrity)- IgA in
EN (IgA prevent absorption of enteric antigen) - less risk
for infection
– Promote peristalsis
– Safer: fewer complication
– Lower cost-formula, delivery system and less patient care
– Simpler system-care and self-administrator
TRANSNASAL PASSAGE
• Transnasal passage of feeding into the stomach/intestine
employed when possible

– Advantages:
• A surgical procedure can be avoided
• Generally well tolerated when small-bore feeding tube are used

– Disadvantages:
• Tube can be readily removed by disorientated/uncooperative pt.
• When larger, stiffer tube used - irritation to nasal passages,
pharynx, esophagus & compromise gastroesophageal
competency
 Enteral Indications Advantages Disadvantages
Access Site

Nasogastric Normal GI function Uses and stimulates Aspiration;

normal digestive function; discomfort for
flexibility in patient; nasal
administration; irritation; tube
medications can be placed displacement
in this tube; tube insertion
at bedside
Nasoduodenal Normal small intestine Tube insertion at bedside Discomfort for
function; need to bypass patient; tube
stomach as primary site displacement
of feeding
Nasojejunal Normal small intestine Tube insertion at bedside Discomfort for
function; need to bypass patient; tube
stomach as primary site displacement
of feeding
TUBE FEEDING ROUTES
OSTOMIES
• Require surgical or non surgical insertion.

• Indicated when insertion through transnasal is impossible or

when long-term feeding is anticipated

• Advantages:
– Irritation caused by the feeding tube is eliminated

• Disadvantage:
– Possibility of infection is high like other ostomy procedure
Enteral Access Indications Advantages Disadvantages
Site
Gastrostomy & Normal GI function but Reduced risk of tube Surgical procedure; risk
esophagostomy need to bypass upper GI displacement; allows for of irritation and
tract; longer-term feeding bolus feedings infection for insertion
access site

PEG Normal GI function but Outpatient procedure without Risk of irritation and
(percutaneous need to bypass upper GI risk of anesthesia; longer- infection for insertion
endoscopic tract; longer-term feeding term feeding access; less site
gastrostomy) access expensive than surgical
insertion; reduced risk of
tube displacement; allows
for bolus feedings

Jejunostomy Normal GI function but Increased tolerance for early Surgical procedure; risk
need to bypass initiation of enteral feeding of irritation and
components of GI tract; infection for insertion
longer-term feeding site; with smaller
access lumen of tube, the risk
of clogging may be
greater
• Gastrostomy (PEG):
– The percutaneous endoscopic gastrostomy (PEG) is a
nonsurgical technique for placing a tube directly into the
stomach through the abdominal wall, performed using an
endoscopy.

– The preferred access route for patients requiring tube

feeding for more than 3 to 4 weeks because of its ease in
providing feeding.
• Jejunostomies (PEJ):
• Percutaneous endoscopic Jejunostomy

• Permits early post operative feeding (unlike stomach &

colon) - the small bowel is not affected by postoperative
ileus.

• Relatively safe, comfortable, potential for long-term use

METHODS OF DELIVERY
Based on:
 Nutrient needs
 Feeding site
 Formula selection
 Current medical status

3 methods of delivery:
1. Bolus feeding
2. Intermittent bolus feeding
3. Continuous feeding
BOLUS FEEDING
INTERMITTENT/
CONTINUOUS FEEDING
(KANGAROO PUMP)
METHODS OF ENTERAL
FEEDING DELIVERY
• Continuous feeding - delivers formula at a nonstop flow rate to
achieve daily nutrition targets.
• Intermittent feeding – given periodically over time (eg. 2-3 hrs of
feeding followed by 2 hrs of rest).
• Bolus feeding – given all at once but with feeding multiple times a
day (eg. Pt. is fed a vol of 250-400ml of formula in 15 minutes, with
3-8 times/day).
 Feeding How Where Who Why
Regime*
Bolus Gravity/ Stomach only, Patients who Mimics normal
syringe as small bowel need/prefer extended meals; does not
lacks reservoir breaks from feeding require a pump
capacity
Intermittent Pump/ Small Patients who are Slowed feeding
gravity bowel/stomach mobile/have other rate is possible
reasons for non- even when a
continuous feeding pump is
unavailable
Continuous Pump Small Critically ill patient Continuous, slow
bowel/stomach Patient at risk of rate enhances GI
reflux/aspiration tolerance
Individuals intolerant of
intermittent/bolus
feeding
DELIVERY DEVICE
Delivery device Pump

Preferred for: • Small bowel feeding

• Pt. with severe reflux, risk of aspiration pneumonia
& severe diarrhea

Advantages/ • Can deliver precise & consistent amounts to pt. with

disadvantages volume sensitivity
• Can deliver slow & continuously amounts over many
hrs. to enhance GI tolerance
• Pump feeding results in lower rates of vomiting,
aspiration pneumonia & severe diarrhea
• May not be available/feasible in some settings
• Restricts pt. movement
DELIVERY DEVICE

Delivery device Gravity

Preferred for: • Stable pt.

Advantages/ disadvantages • Commonly available

• Appropriate for bolus stomach feeding - allow
pt. greater freedom/movement between feeding
times
• Delivery rates are less reliable than pump
• Intended flow rate can be altered when pt.
changes position
TYPES OF ENTERAL
PRODUCTS
TYPES OF ENTERAL
PRODUCTS
• Standard/polymeric formulas
• Elemental (hydrolyzed) formula
• Modular (Supplements)
• Condition-specific
 Category Characteristic Indication Products

Standard Nutritionally complete Normal Ensure FOS/Nutren

Provide 1 kcal/ml digestive & Optimum/Penta Sure
Distribution: absorptive Balanced/Optimaxe
capacity Lite/Osmolite
50-60 % - CHO
10-15 % - Protein
25-30 % - Fat
Fiber- Similar to standard formula Constipation, Jevity/Nutren
supplemented except for fiber content diarrhea Fibre/Gucil/
4-20g of dietary fiber/l Hexbio

Concentrated Similar to standard formula High calorie, Enercal Plus/Penta

except provide 1.5-2.0 kcal/ml high protein Sure 2.0
POLYMERIC FORMULA

• Composed of intact proteins, disaccharides, polysaccharides,

variable amounts of fat and residue
• Require a functioning GIT for absorption and digestion
POLYMERIC FORMULA
Category Characteristic Indication Products
Standard Nutritionally complete Normal Ensure
Provide 1 kcal/ml digestive & FOS/Nutren
Distribution: absorptive Optimum/Penta
capacity Sure
50-60 % - CHO
Balanced/Optima
10-15 % - Protein xe Lite/Osmolite
25-30 % - Fat
Fiber- Similar to standard Constipation, Jevity/Nutren
supplemented formula except for fiber diarrhea Fibre/Gucil/
content Hexbio
4-20g of dietary fiber/l
Concentrated Similar to standard High calorie, Enercal
formula except provide high protein Plus/Penta Sure
1.5-2.0 kcal/ml 2.0
POLYMERIC FORMULA
ELEMENTAL FORMULA
- PARTIALLY HYDROLIZED PROTEIN
Characteristic Indication Products
• Nutritionally Reduced digestive & Peptamen/Peptamen
complete absorption capacity Jr./Semital
• Usually provide (e.g. Crohn’s Disease,
1 kcal/ml Short Bowel Syndrome,
• May contain long term fasting with
glutamine gut atrophy, post
operative patients)
ELEMENTAL FORMULA
- PARTIALLY HYDROLIZED PROTEIN
MODULAR FORMULA
• Modular Formulas
– Single nutrient supplement, nutritionally incomplete,
usually low in electrolytes
Examples :
 Fat - MCT oil (Medium Chain Triglyceride)
 CHO - Carborie, Polycose (Glucose polymer)
 Protein - Myotein
 Thickening Agent – Thixer
 Glutamine - Glutarich
MODULAR FORMULA
CONDITION-SPECIFIC
FORMULA
Condition Characteristic Indications Product
Liver Disorder •Formulated with BCAA Hepatic Hepa Pro/Penta
•Provides 1.0-1.5kcal/ml Encephalopathy Sure Hepatic
•Calorie dense for fluid , cirrhosis,
mgmt NASH,
hepatitis
Glucose •Nutritionally complete Hyperglycemia Glucerna
Intolerance & •Provides 1.0 kcal/ml :> 10 mmol/L RTD/Nutren
Diabetic •Low in CHO: 35% of Diabetik/ Penta
kcal sure
DM/Diabetisol/
•High in fat: 40-50% of
Glucerna
kcal
TripleCare/Wellne
•Fiber supplemented ss 60+
Diabetic/Suppleme
nt D
CONDITION-SPECIFIC
FORMULA
Condition Characteristic Indications Product

Electrolyte and •Provides 1.5-2.0 kcal/ml Acute or Novasource

Fluid restriction •Moderate in protein chronic renal Renal/Nepro
& Renal •Low in electrolytes failure requiring HP/Penta Sure
dialysis Renal/Penta sure
DLS/Reno-pro
High
Protein/Reno-pro
Low Protein
Burn, Cancer & •Immune-enhancing ICU, cancer, Prosure
High Protein nutrition for critically ill Traumatic (EPA)/Neo-mune/
•Provide 1.0-1.3 kcal/ml injury, pre & Penta Sure
post surgery Immunomax/
Promaxe
IMMUNE-ENHANCING FORMULAS
• Have added “immune-enhancing” nutrients (arginine,
glutamine, omega-3 fatty acids, nucleotides)

• Results of research have been mixed. Multiplicity of active

ingredients makes it difficult to control variables

• The use of EN supplemented with arginine and other selected

immune nutrients in critically ill patients is not recommended.
Potential of harm among patients with severe sepsis (Grade A)

• The routine use of EN glutamine in critically ill patients is not

recommended (Grade A)

(MNT Critically Ill, 2017)

 EVIDENCE- BASED
• The routine use of EN glutamine in critically ill patients is not recommended.
Potential harm has been reported in patients with shock and multi-organ
failure (Grade A)

• There is insufficient evidence to make a recommendation on the

supplementation of fish oils alone in critically ill patients.

• The addition of probiotics to EN appears to be safe and may be used for

critically ill patients, esp. in pt. with high risk of infections, pneumonia
(Grade A)

• For the trauma patient, it is not recommended to routinely use immune-

enhancing EN, as its use is not associated with reduced mortality, reduced
LOS, reduced infectious complications or fewer days on mechanical
ventilation.

(MNT Critically Ill, 2017)

FORMULAS FOR IMPAIRED GI FX:
INFANT/CHILDREN
• Hydrolyzed (Amino Acid Based formula)
– Comidagen & Comidagen Plus
• Lactose Free
– Nan AL
• Anti Reflux
– Enfalac A+AR & Enfalac AR
• Soy Based
– Isomil
• Semi-Elemental
– Mamex Gold Pepti & Peptamen Jr.
INITIATION OF ENTERAL
NUTRITION
INITIATION OF FEEDING

• Choose full strength, isotonic formulas for initial feeding regimen.

• Initiation and advancement of enteral formula in pediatric patients is
best done over several day in a hospital setting using a flexible
nutrition plan.
INITIATION OF FEEDING

• Slow initiation may significantly delay the patient

receiving his full nutritional requirements, but may be
necessary for:
– patients who are at risk of refeeding syndrome, bowel
ischaemia or feeding intolerance
– anyone who has been nil-by-mouth for a prolonged period,
the critically ill, existing eating disorder or alcoholism, or
those who have had major surgery (eg. abdominal surgery)
INITIATION OF FEEDING-
ADULTS
• Bolus feedings & gravity-controlled feedings
– Full-strength formula, 3-8 times per day
– Increases of 60-120 ml every 8-12 hours as tolerated up to the goal
volume.

• Pump-assisted feedings
– Initiated at full strength at 10-40 ml/hr and advanced to the goal rate in
increments of 10-20 ml/hr every 8-12 hours as tolerated

(JPEN, 2009)
INITIATION OF FEEDING-CHILDREN
• Bolus feedings & gravity-controlled feedings
– Started with 25% of the goal volume divided into the desired number of
daily feedings
– Formula volume may be increased by 25% per day as tolerated, divided
equally between feedings

• Pump-assisted feedings
– A full-strength, isotonic formula can be started at 1-2 ml/kg/hr and
advanced by 0.5-1 ml/kg/hr every 6-24 hrs until the goal volume is
achieved
# For preterm, critically ill, or malnourished children
– Use pump, initial volume : 0.5-1 ml/kg/hour
– Advancing to 10-20 ml/kg/day (JPEN, 2009)
INITIATION OF FEEDING-
PEDIATRIC
Continuous feeding
• Generally children are started:
– Isotonic formula at a rate of 1-2 ml/kg/hr for smaller children
– 1ml/kg/hr for larger children over 35-40 kg.
– The rate is advanced based on tolerance by the child
– The goal of providing 25% of the total calorie needs on day 1.

Bolus feeding
– 2.5-5 ml/kg can be given 5-8 times per day with gradual increases in
this volume to decrease the number of feedings to closer to 5 times
daily.
(JPEN, 2009)
PATIENT POSITIONING
• In critically pt, elevation of head of bed to 30º - 45º
(reduce risk of aspiration pneumonia), for all patients
receiving EN unless a medical contraindication exists.
– Eg. Unstable supine, hemodynamic instability, prone position

(MNT Critically Ill, 2017)

 FLUSHES-PRACTICE
RECOMMENDATIONS
• Flush feeding tubes with 10-30 mL of water every 4 hours during
continuous feeding or before and after intermittent feedings in an adult
patient (depends on fluid requirement).

• Flush the feeding tube with 30 mL of water after residual volume

measurements in an adult patient.

• Flushing of feeding tubes in neonatal and pediatric patients should be

accomplished with the lowest volume necessary to clear the tube.
MEDICATION ADMINISTRATION

• Do not add medication directly to an enteral feeding formula.

• Avoid mixing together medications intended for administration through

an enteral feeding tube to reduce risks of:
– physical and chemical incompatibilities,
– tube obstruction
– altered therapeutic drug responses

• Dilute medication appropriately prior to administration.

NUTRITION SUPPORT
PRACTICES
DO NOT!!!
1. Assemble feeding system on the pt’s bed
2. Top up fresh formula until the formula hanging in the
feeding bag has finished
3. Overfed patients:
– High calorie density formula
• 1.3 kcal/ml  Perative
• 2.0 kcal/ml  Nepro/Enercal plus
CONCLUSION
•Practice early enteral feeding

•Use strict protocols

•Identify & rectify tube displacement

•Alter method of feeding (routine cycling, smaller volume, concentrated

feeds)

•Works as Nutrition Support Team

•Continuous Nutrition Education

REFERENCES
• Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P. Prevalence of malnutrition
and 12-month incidence of mortality in two Sydney teaching hospitals. Int Med J 2001;
31: 455-461.
• Lazarus C, Hamlyn J. Prevalence and documentation of malnutrition in hospitals: a case
study in a large private hospital setting. Nutr Diet 2005; 62(1): 41-47.
• McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and
Assessment ofNutrition Support Therapy in the Adult Critically Ill Patient: Society of
Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.). JPEN J Parenter Enter Nutr. 2016;40(2):159-211.
• Journal of Parenteral and Enteral Nutrition. Vol. 33(2), 2009.
• Medical Nutrition Therapy (MNT) Guidelines for Critically Ill Adults, 2 nd Edition
(2017).