ENTERAL NUTRITION

USING HARRIS-BENEDICT EQUATION

Calories Calculation

BMR(male) = 66 + (13.7 x W in kgs.) + (5 x H in cms.) - (6.8 x Age in yrs.)

ACTIVITY & STRESS FACTORS USED WITH HARRIS-BENEDICT EQUATION

Activity Factors Values Stress Factors Values

Sedentary 1.2 Fever 1.2

Active 1.3 Sepsis 1.3

Cancer 1.6

Surgery 1.0

Starvation 0.70

20% Burn 1.0 – 1.5

40% Burn 1.5 – 1.8

40% - 100% Burn 1.8 – 2.0

TUBE FEEDINGIndications for tube feeding:Comatose patientSeverely debilitatedPatients who have gone undergone radical facial or neck surgery.

Oral intake is inadequate or contraindicated

Increased nutritional requirements

ENTERAL FORMULA CATEGORIES

Polymeric formulas

Oligomeric formulas

POLYMERIC FORMULASComposed of intact proteins, disaccharides and polysaccharides and variable amount of fat.Similar to average diet.Calorie density 1kcal/mlNitrogen concentration of 5-7g/1000ml  Requires an intact gut for digestion.Also includes disease specific formulas. Lactose free and most are gluten free Can be used orally also .Examples are ISOCAL, ENSURE, GLUCERNA etc

SUBCATEGORIES OF POLYMERIC FORMULAS

CALORIC DENSE FORMULAS 2 kcal/ml or 1.5 cal/ml Fluid restriction, Volume

intolerance, Electrolyte abnormalities

Examples are Novasource Renal, Suplena, Ensure plus FIBER CONTANING FORMULAS

Fiber 5 -15g/L For regulation of bowel

movement Examples are Ensure,

Glucerna

DISEASE SPECIFIC FORMULAS

RENAL FORMULA Calorie dense, low

electrolytes, vary in proteins

Renal failure

Target to minimize BUN reduce accumulation of toxic waste , maintain electrolyte & water balance .

Examples are NOVASOURCE RENAL, SUPLENA

HEPATIC FORMULA High in BCAA, low in AA, low

in electrolytes.

Hepatic failure, encephalopathy

Reduced in aromatic amino acids & methionine , so as to correct abnormal plasma  ratio of theses amino acid.

Example is SUPLENA

DIABETIC FORMULA

Low in CHO

High fiber content.

Sucrose free

Example Glucerna, Glucerna SR, Boost Diabetic

PULMONARY FORMULA

Deterioration of nutritional status in critically ill patients with respiratory insufficiency is associated with

reduction of respiratory muscle mass

problems in weaning from vent ,

Patient tend to retain Co2. Can be corrected by using formula with higher fat than CHO ratio

Example is PULMONARY FORMULA

IMMUNE ENHANCING FORMULA

Metabolic stress, immune dysfunction.

Arginine, glutamine, omega 3 FA, anti oxidants

Examples are ENSURE PLUS, IMPACT

OLIGOMERIC FORMULASElemental formula

Partially hydrolyzed.

Hyperosmolar

Contains nitrogen in the form of free amino acids or peptides.

Impaired digestive and absorptive capacity

Example is VITAL HN, PEPTAMEN

FORMULA SELECTION

Selection of appropriate formula should be based on the individual patient’s:

Medical and nutritional statusDigestive and absorptive capabilitiesIndividual nutrient requirements

ADMINISTRATION OF TUBE FEEDING

Methods of Feeding

Continuous infusion Intermittent infusionBolus feeding

GUIDELINES FOR INITIATING ENTERAL FEEDINGContinuous Feeding

Begin undiluted feeding at a rate between 10 and 50ml/hr.Greater doubts about GI functions should prompt lower infusion rates.

Increased the rate in increments of 20-40ml/hr, every 8-24hrs to attain the required rate( calculated to meet energy and protein requirements), in as little as 1 day or as many as 5 days, depending on the state of GI tract.

The final rate should not exceed 125-150 ml/hr: high nutrient requirement should met with 1.5-2 kcal/ml formulas.

DISCONTINUATION OF FEED

Discontinue enteral feeding only when adequate oral intake has been achieved.

When the likelihood of achieving oral intake is uncertain, use weaning methods such as

reducing the infusion rate, interrupting the infusion before

meals infusing only at night to

improve appetite and oral intake during the day.

Bolus Feeding Begin with 50-100ml boluses of

undiluted feeding every 2-4 hrs. Increase the size of boluses every 8-24 hrs, to 100ml, 150ml, 200ml. Etc. until requirements are met.

In alert patients it is often possible to begun with 250ml boluses and increase the volume to as high as 400ml/feeding. If possible avoid feeding during the night.

If water requirements are not met by the formula, additional water should be given with the flush.

Wean patients to oral intake by eliminating feedings that precede meals. Discontinue enteral feedings only when adequate oral intake has been achieved.

Ref:Douglas C. Hemiburger, Jamy D. Ard “Hand Book Of Clinical Nutrition”, 3rd edition 2006, page no. 319

HOW TO WRITE ENTERAL FEED PRESCRIPTION

All orders for tube feeding must include the following information

Formula Formula volume per feeding (ml only) and total formula volume/24 hrsFrequency of feedingsAdditives ( carbohydrate or protein powders, etc.: Amount added to each feeding in table spoons, tea spoons, ml or ounces and total amount per 24 hrs) cont.

Tube Type (G.T., N.G. or J.J.)

Feeding Method: Pump (including administration rate), bolus or Gravity (number of minutes for feeding)

Flushes ( feeding and medication) before, after or both

Ref: ‘DIET MANUAL’ State of California Dept of Development Services, 2003. Revised 2004&2009

COMPLICATIONS OF TUBE FEEDINGGASTROINTESTINAL

COMLICATIONS1. Diarrhea Causes

Hypertonic feeding formulas Hypoalbunemia Bacterial contamination Inadequate fiber in feeding

formulas Certain infusion methods (e.g.

bolus infusions or rapid increases in infusion rates)

Medications Elixir medications containing

sorbitol Magnesium containing antacids Oral antibiotics (definite); IV

antibiotics?, Phosphorous supplements, histamine-2 receptor blockers, metaclopramide, other assorted medications.

MANAGING DIARRHEA IN TUBE FEEDING

Do’s Carefully review all medications

Eliminate all elixirs containing sorbitol

Eliminate Mg containing antacids Eliminate any other potential

offenders Consider giving psyllium (ispaghol) or

pectin.Don'tsDon’t stop the feeding any longer than is

necessary to determine whether it is causing diarrhea.

Don’t change the feeding formula with the assumption that doing so will relieve the diarrhea

Ref: Douglas C. Hemiburger, Jamy D. Ard “Hand Book Of Clinical Nutrition” 2006 page no. 322,

2.CONSTIPATION

Causes: Inactivity Decreased bowel

motility Decreased fluid

intake Lack of dietary

fiber Poor bowel motility

and Dehydration

Treatment Bowel stimulants Adequate hydration Use of fiber-

containing formulas Stool softeners

3.NAUSEA AND VOMITING

Causes Delayed gastric

emptying

Abdominal distention

Treatment

Reducing narcotic medications

Switching to a low-fat formula

Administering the feeding solution at room temperature

Reducing the rate of administration

Administering a promotility

Check gastric residuals before the next bolus feeding, or every four hours for continuous feeding.

If gastric residuals are low yet nausea persists, consider antiemetic medications.

MECHANICAL COMPLICATIONS 1) Aspiration

Risk factors for aspiration include:

Decreased level of consciousness

Diminished gag reflex Neurologic injury GI reflux Supine position Use of large-bore feeding

tubes Large gastric residuals

Use of small-bore feeding tubes, promotility agents, periodic assessment of gastric residuals, and keeping the head of the bed elevated may reduce the risk of aspiration

2)Tube malposition 3)Tube Clogging

METABOLIC COMPLICATIONSPOSSIBLE ETIOLOGY POSSIBLE CAUSE POSSIBLE TREATMENT

Hyponatremia Excessive free water,Abnormal sodium loss

Change to fluid restricted formula,Discontinue water boluses, replace sodium losses

Hypernatremia Inadequate hydration,Increased fluid loses,Diabetic Insipidus

Add or increase water boluses or IVF

Hypokalemia Anabolism, refeeding, diuretics, medications

Supplement K

Hyperkalemia Renal failure, metabolic acidosis, catabolism, GI bleed, acute dehydration

Correct imbalanceChange to renal formula as appropriate

POSSIBLE ETIOLOGY POSSIBLE CAUSE POSSIBLE TREATMENT

Hypophosphatemia AnabolismRefeeding

Supplement Phosphorus

Hyperphospatemia Renal failure Change to renal formulaPhosphate binders

Hypomagnesimia Anabolism, refeeding, diuretics, medications

Supplement Mg

Hyperglycemia Diabetes, Steroid therapy, Sepsis, Trauma, Pancreatitis

Change to diabetic formulaInsulin drip per protocolGoal is to maintain blood glucose at or < 110 mg/dl

Ref: ‘ Enteral feeding guidelines, Harbor view Medical Centre, Katie Farver, RD, CD

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