enteral nutrition finall
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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
THANK YOU
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