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Enteral Nutrition for
Adults
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Contraindications for EN
♦Severe acute pancreatitis
♦Inability to gain access
♦Intractable vomiting or diarrhea
♦Aggressive therapy not warranted
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Contraindications for EN♦Inadequate resuscitation orhypotension; hemodynamic
instability♦Ileus
♦Intestinal obstruction
♦Severe GI !leed
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Indicators of Adequate "luid
#esuscitation in Critically Ill $ts♦%rine output should be &'( ml)hour ♦*eart rate +,-( beats)minute; preferably
+,(( beats)minute♦Systolic !$ should be .,((
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Nasogastric /ubes
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Nasogastric /ubes
0efinition
♦A tube inserted through the nasal passageinto the stomach
Indications1
♦Short term feedings required
♦ Intact gag refle2
♦Gastric function not compromised
♦3ow ris4 for aspiration
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"rench %nits5/ube Si6e♦0iameter of feeding tube is measured in"rench units
♦ ," 7 '' mm diameter
♦ "eeding tube si6es differ for formula types and
administration techniques
♦Generally smaller tubes are more comfortable
and better suited to NG or N8 feedings
♦9ay be more li4ely to clog with viscous
formula or formula mi2tures
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Nasogastric /ubes
Advantages1
♦ Ease of tube placement
♦ Surgery not required
♦ Easy to chec4 gastric residuals
♦ Accommodates various administration techniques
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Nasogastric /ubes
0isadvantages1
♦ Increases ris4 of aspiration :maybe
♦ Not suitable for patients with compromised gastric
function
♦ 9ay promote nasal necrosis and esophagitis
♦ Impacts patient quality of life
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Nasoduodenal)8e
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Nasoduodenal)8e
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Nasoduodenal)8e
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=rogastric
♦/ube is placed through mouth and into
stomach
♦=ften used in premature and small infants
as they are nasal breathers
♦ Not tolerated by alert patients; tubes may be
damaged by teeth
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Gastrostomy>
8e
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Enterostomy $lacement
♦ Gastrostomy
♦ 8e
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Gastrostomy
0efinition
♦ A feeding tube that passes into the stomach
through the abdominal wall 9ay be placed
surgically or endoscopicallyIndications1
♦ 3ong>term support planned
♦ Gastric function not compromised♦ Intact gag refle2 present
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Gastrostomy
0isadvantages1
♦ 9ay require surgery
♦ Stoma care required
♦ $otential problems for lea4age or tube
dislodgment
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Gastrostomy
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8e
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8eop feedings may be initiated immediately
♦ 0ecreased ris4 of aspiration
♦ Suitable option for patients with compromised
gastric function
♦ Stable patients can tolerate intermittent feedings
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8e
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0etermining 9ethod of
Administration
♦ "eeding site
♦ Clinical status of patient
♦ /ype of formula used
♦ Availability of pump
♦ 9obility of patient
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Initiation of Enteral "eedings
♦0ilution of enteral formulas not generally
recommended
♦ Initiate at full strength at slow rate and
steadily advance
♦Allows achievement of goal rates more
quic4ly; less manipulation of formula
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Administration♦!olus
♦ Intermittent
♦
Continuous♦Cyclic
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!olus "eedings
0efinition
♦ Infusion of up to ?(( ml of enteral formula into
the stomach over ? to -( minutes@ usually by
gravity or with a large>bore syringeIndications1
♦ #ecommended for gastric feedings
♦ #equires intact gag refle2♦ Normal gastric function
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!olus "eedings
Advantages1
♦ 9ore physiologic
♦ Enteral pump not required
♦ Ine2pensive and easy administration
♦ 3imits feeding time so patient is free to ambulate@
participate in rehabilitation@ or live a more normal
life in the home♦ 9a4es it more li4ely patient will receive full
amount of formula
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!olus
"eeding
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!olus "eeding
0isadvantages1
♦ Increases ris4 for aspiration
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Continuous "eedings
Indications1
♦ Initiation of feedings in acutely ill patients
♦ $romote tolerance
♦ Compromised gastric function
♦ "eeding into small bowel
♦ Intolerance to other feeding techniques
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Continuous "eedings
0efinition
♦ Enteral formula administration into the
gastrointestinal tract via pump or gravity@ usually
over to -B hours per day
Advantages1
♦ 9ay improve tolerance♦ 9ay reduce ris4 of aspiration
♦ Increased time for nutrient absorption
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Continuous "eedings
0isadvantages1
♦ 9ay reduce -B>hour infusion
♦ 9ay restrict ambulation
♦ 9ore e2pensive for home support
♦ $umps are more accurate; useful for small>bore
tubes and viscous feedings@ but many payers have
strict criteria for approval of pumps for home or3/C use
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Intermittent "eedings
0efinition♦ Enteral formula administered at specified times
throughout the day; generally in smaller volume andat slower rate than a bolus feeding but in largervolume and faster rate than continuous drip feeding
♦ /ypically -((>'(( ml is given over '(>( minutes qB> hours
♦ $recede and follow with '(>ml flush of tap water
Indications1
♦ Intolerance to bolus administration
♦ Initiation of support without pump
♦ $reparation of patient for rehab services or dischargeto home or 3/C facility
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Intermittent "eedings
Advantages1
♦ 9ay enhance quality of life
D Allows greater mobility between feedings
D 9ore physiologic
D 9ay be better tolerated than bolus
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Intermittent "eedings
0isadvantages1
♦ Increased ris4 for aspiration
♦ Gastric distention
♦ 0elayed gastric emptying
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Cyclic "eedings
0efinition
♦ Administration of enteral formula via continuous drip over
a defined period of to ,- hours@ usually nocturnally
Indications1
♦ Ensure optimal nutrient inta4e when1
D /ransitioning from enteral support to oral nutrition
:enhance appetite during the day D Supplement inadequate oral inta4e
D "ree patient from enteral feedings during the day
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Cyclic "eedings
Advantages1
♦ Achieve nutrient goals with supplementation
♦ "acilitates transition of support to oral diet
♦ Allows daytime ambulation
♦ Encourages patient to eat normal meals and snac4s
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Cyclic "eedings
0isadvantages1
♦ 9ay require high infusion rates5may promote
intolerance
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Enteral "eeding Complications
♦ 9echanical
♦ Gastrointestinal
♦ 9etabolic
♦ Infectious
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9echanical
♦ "eeding tube obstruction
♦ "eeding tube dislodged
♦ Nasal irritation
♦ S4in irritation)e2coriation at ostomy site
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Causes of "eeding /ube =bstruction
♦ Concentrated@ viscous@ and fiber>containingfeeding products
♦ /ube feeding contamination
♦ Chec4ing of gastric residuals♦ Small diameter tubes
♦ $owdered or crushed medication flushed throughtubes
♦ Acidic or al4aline medications passed throughtubes
♦ /ubes not routinely flushed after feedings arestopped
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$revention of "eeding /ube
=bstruction♦"lush the feeding tube@ especially before
and after medication administration and bolus)intermittent feedings
♦%se liquid formulations of medicines where possible :but be careful of osmolarity
♦0o not mi2 medications with enteral
feedings unless shown to be compatible♦Avoid crushing enteric>coated tablets
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/reatment of
"eeding /ube =bstruction♦0eclog with irrigants :warm water or
sodium bicarbonate)pancrealipase mi2ture
or by mechanical means
♦Cola beverages@ cranberry
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Aspiration
♦#eported incidence of aspiration in tubefed
patients varies from to H? Clinically
significant aspiration ? gastric>fed pts
♦9any aspiration events are silentJ and
often involve oropharyngeal secretions
♦Symptoms include dyspnea@ tachycardia@
whee6ing@ rales@ an2iety@ agitation@ cyanosis
♦9ay lead to aspiration pneumonia
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Aspiration $revention
♦Keep head of bed elevated '(>B? degreesduring and '(>B( minutes after feedings
♦"eed post>pylorically :research mi2ed on
this♦Small@ frequent feedings or continuous drip
♦%se of promotility agents
♦9onitoring of gastric residuals may behelpful in identifying delayed gastricemptying and increased ris4 of aspiration
/he AS$EN Nutrition Support $ractice 9anual@ -nd Edition@ -((?
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Gastrointestinal Complications
♦ 0iarrhea
♦ Constipation
♦ Gastric distention)bloating
♦ Gastric residuals)delayed gastric emptying
♦ Nausea)vomiting
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0iarrhea
♦ 0efinition1 &?(( ml every hours or more than '
stools a day for at least two consecutive days
#elates more to stool consistency than frequency
♦ 0iarrhea was a common consequence of enteralfeedings when hyperosmolar feedings were
routinely delivered via syringe
♦ =ccurs in - to ' of enterally>fed pts depending
on how defined
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Causes)/reatments of 0iarrhea
♦ Intestinal atrophy due to malnutrition
D EN is the best stimulant for recovery Increase
rate slowly as tolerated
D Albumin infusion is unli4ely to be helpful;diarrhea is not caused by low albumin; it is a
mar4er of malnutrition
♦
!olus feeding in the small intestine1 resultsin dumping syndrome
D %se an infusion pump to regulate flow
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Causes)/reatments of 0iarrhea
♦!acterial overgrowth of intestinal tract orcontamination of the enteral feeding D Avoid prolonged use of broad>spectrum
antibiotics D %se clean technique and closed system in
handling enteral feedings
D 3imit hang time of open system formulas to
hours :B hours for mi2tures D Change bag and tubing per protocol
D /est for C difficile and other pathogens beforeusing anti>motility agents
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Causes)/reatments of 0iarrhea
♦Steatorrhea1 characteri6ed by frothy@
odiferous stools that float on water; caused
by fat intolerance
D %se lowfat enteral formula or one with higher
percentage of 9C/; pancreatic en6ymes may
help in pancreatic insufficiency
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Causes)/reatments of 0iarrhea
♦3actose intolerance D 9ost enteral products are lactose free but this
may occur with initiation of full liquid diet
Eliminate mil4 and dairy products♦0rug>induced diarrhea
D 9eds may cause up to , of diarrhea intubefed pts due to hypertonicity or direct
la2ative action :magnesium@ sorbitol@ potassium 0iarrhea most common withantibiotics 0iscuss with 90)pharmacist
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Causes)/reatments of 0iarrhea
♦ Infusion of hypertonic feeding solutions;
rare unless delivered at very high rate or
bolused into small bowel
D /ry a different product rather than diluting the
original feeding
♦GI disease1 such as I!S@ short gut@ celiac
disease@ AI0S D 9ay require $N or specially formulated EN
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/reatment of 0iarrhea in General
♦Add soluble fiber :such as banana fla4es or
!enefiber or insoluble fiber such as
psillium
♦Consider an enteral formula with added
fiber
♦%se an antidiarrheal agent :loperamide@
dipheno2ylate@ paregoric@ octreotide
♦Change the formula
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Nausea)Lomiting
♦ -( of patients on EN report
nausea)vomiting
♦=ften related to delayed gastric emptying
caused by hypotension@ sepsis@ stress@
anesthesia@ medications :analgesics and
anticholinergics@ surgery
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Nausea)Lomiting /reatment
♦ Consider reducing)discontinuing narcoticmedications
♦ Switch to a lowfat formula
♦ Administer feeding solution at room temperature♦ #educe rate of infusion by -(>-? ml)hr
♦ Administer pro4inetic agent :metoclopramide@erythromycin@ domperidone@ bethanechol
♦ Chec4 gastric residuals♦ Consider antiemetics
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9etabolic
♦ "luid and Electrolyte abnormalities
♦ Glucose intolerance
♦ CaMM@ 9gMM@ $=B abnormalities
♦ =ther
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"luid and Electrolyte
0isturbances♦9ay result from long term nutrition deficits@
acute stress@ medications@ medical
conditions@ improper nutrient prescription
♦Electrolytes lost via stool@ urine@ ostomy or
fistula drainage
♦0ehydration most common complication
:tube feeding syndrome especially with
high protein feeding and insufficient fluid
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9onitoring of $atients on EN
♦ Electrolytes
♦ !%N)Cr
♦ Albumin)prealbumin
♦ CaMM@ $=B@ 9gMM
♦ eight
♦ Input)output
♦
Lital signs♦ Stool frequency)consistency
♦ Abdominal e2amination
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