JENNIFER GRAF, MS, RDLIEUTENANT COMMANDER, USPHS

NUTRITION DEPARTMENTNATIONAL INSTITUTES OF HEALTH

JUNE 21, 2012

Enteral Nutrition During Deployment

Disclaimers

Brand name formulas are included for purposes of education and their inclusion does not

reflect bias or endorsement of a particular product or brand.

Suggestions for short-term solutions when specialized formulas are not available are often

based on my personal judgment rather than evidence. I hope to discuss others’ suggestions

as well.

Outline of Talk

Set the scene for deployment

Review enteral nutrition guidelines in the context of deployment

Assess the need for specialized formulas in various disease conditions

Walk through case studies

Subject Matter Experts

Ship Deployment CDR Kathleen Edelman CDR Pamella Vodicka

Federal Medical Station (FMS) CDR Blakeley Fitzpatrick LCDR Merel Kozlosky Coppola, Dean, CAPT, USPHS. “Leadership of a

Federal Medical Station-Special Needs Shelter” slide presentation

Ship Deployments

Challenges to Optimal Care

Space is limited for supplies and staff Replenishment of supplies can be delayed

Must keep close tabs on supply and par level Specialty items require much coordination Limited phone/email access NJ tube feed placement may be appropriate given

seasickness Must prioritize time and demand on others Plans/recommendations must be simple

CDR Vodicka meeting with an enterally fed patient in Trinidad

Reed Arena, College Station, TXHurricane Ike

Special Needs Patient

Any individual who would need assistance to evacuate and shelter due to physical or mental disabilities and/or someone who requires the level of care and resources beyond the care available in a general population shelter, yet does not require hospitalization.

Examples: behavioral health, hospice, morbid obesity, diabetes, respiratory disease, hypertension, orthopedic, gastrointestinal disease

Taken from: Coppola, Dean, CAPT, USPHS. “Leadership of a Federal Medical Station-Special Needs Shelter” slide presentation.

FMS- Hurricane Ike, College Station, TX 2008

Special Needs Category (9/16/08) 0 7% 1 16% 2 12% 3 24%4 26%***5 15%***

Provided courtesy of CAPT Dean Coppola

Hurricanes Rita, Gustav, and Ike

Types of Patients Seen Chronic diseases

Renal disease Diabetes Mellitus Degenerative neurologic disorder with dysphagia Nursing home residents

Higher acuity Burn patients on TPN/TF (accompanied by nurses and

supplies) Ventilated patient s/p GSW on TF (brought own formula)

Tube feeding patients Usually came with some formula supply, but often no

instructions

Hurricanes Rita, Gustav, and Ike

Supplies in FMS Cache Formulary of enteral formulas (not official list?)

Enfacare, liquid Milk-based Infant formula, liquid Soy-based infant formula, liquid Vanilla supplement, powdered Diabetic formula, powdered Oral rehydration packets

Tube feeding kits May not be fully stocked or substitutions may be made

Hurricanes Rita, Gustav, and Ike (cont.)

Other Challenges

At initial set up, may not have potable water or food Lab values, weights, fluid balance not readily

available Medical history may be incomplete

Dietitians’ Other Responsibilities

Securing food and potable waterScreening over 200 patients

Dysphagia, NPO, special diets

Plating/serving foodMaintaining food par levelsCleaning

Priorities at Arrival to FMS

Assess formulas and supplies in FMS cacheIdentify a local facility (university, hospital, retail store)

that could be a source of specialized or additional formula

Coordinate a contract through the Logistics TeamAssess special formula needsBecome familiar with process of pharmacy orders to IRCTIdentify how tube feeding orders are being

communicatedRecommend patient transfer if unable to safely meet

needs

**Be flexible and make do with what you have while taking the route of least harm to the patient**

Resources to Bring

Food and Nutrition Guide for DeploymentAND Nutrition Care ManualPocket product guides for Abbott, Nestle,

NutriciaAmerican Association of Kidney Patients

Nutrition Counter http://www.aakp.org/userfiles/File/NutritionCounter_English(9).pdf

If deployed to relieve rapid deployment group, contact dietitians at FMS to find out what resources may be necessary.

Work-up for Enteral Feeding

Identify Who Should Receive Enteral Feeds

Oral intake is inadequate Poor appetite Very high needs (trauma, burns, wounds, critical

illness, catch-up growth)

Oral intake is impossible Structural barriers (e.g. tumor, esophageal atresia)

Oral intake is unsafe Impaired swallowing function (neuromuscular disease) Risk for aspiration

AND… GI tract is functional

Absolute Contraindications for Enteral Feeding

Hypovolemia/Hypotension (poor gut perfusion) Never feed until fluid resuscitated and

hemodynamically stable

Bowel obstructionIntractable vomitingUpper GI bleedingHigh output GI fistulas

Site of Enteral Access

Nasal tubesEndoscopically placed ostomy tubes

Gastric Functional stomach Absence of significant delayed gastric emptying, vomiting,

aspiration

Post-pyloric Gastric outlet obstruction Gastroparesis Pancreatitis- Place past Ligament of Treitz Reflux/risk for aspiration- Place past Ligament of Treitz?

Estimate Needs(refer to deployment guide)

Predictive equations are weight-basedEnergy needs

Use ideal body weight if underweight or poor growth Better to under-estimate needs initially and adjust per

hunger or wtProtein needs

Higher for critically illFluid needs

Increased with hot conditions, fever, losses(diarrhea, fistula)

If no weight available Ask the patient Use reference weights for age and adjust

Recommend Feeding Schedule

Bolus-delivered by gravity via a syringe More physiologic Low concern for gastric delay or aspiration

Continuous-delivered using enteral pump at a specified rate for extended period of time Presence of delayed gastric emptying, reflux, dumping

syndrome Suspected risk for refeeding syndrome Overnight feeds Small bowel feeds

Select a Formula

Patient-related factors Nutrient requirements Electrolyte balance Digestive/absorptive

capacity Disease state Renal function Food allergies

Formula-related factors Digestibility of

nutrients Nutrient adequacy Osmolality Viscosity Ease of Use

Final Considerations Before Starting Feeds

Be sure patient is hemodynamically stable and volume replete

Replete electrolytes if at risk for refeedingStart/advance feeds extra slowly using isotonic

formula for: Critically Ill Undernourished Those who have not been enterally fed for an extended

period of timeDo not use formulas that contain fiber or arginine

for critically illProvide adequate free water

Consider all sources: IV’s, water in formula, and flushes May require extra water boluses.

Initiate Feeds

Start formula full strengthAdults: See page 21 of Deployment GuideChildren

Bolus 25% needs or 2.5-5 ml/kg divided among 6-8 boluses over

>15-20 minutes Advance by 25% per day until reach goal Condense to 4-6 boluses per day as tolerated

Continuous 1-2 ml/kg/hr (1 ml/kg/hr for kids >35 kg) Advance 0.5-1 ml/kg/hr every 6-24 hrs

Monitor Patient

WeightFluid status (Ins/Outs)Labs: electrolytes, glucoseActual delivery of formulaGI symptomsReports of hunger/thirst from patientGastric Residual Volumes

Controversial

Minimize Bacterial Contamination

Formula Preparation

Powdered formulas are not sterile; use ready-to feeds (RTF) if available Clean RTF can lids Keep opened RTF formula covered in refrigerator ; expires in 24 hr Prepare formulas in disinfected, separate area with little traffic, no cleaning

supplies and without strong air currents using disposable or heat-sterilized equipment (dishwasher to 180 degrees)

Use chilled, sterile water (can boil 1-2 minutes & cool) Use whisk (not blender) Powdered formula cans: once opened, keep lidded in clean, cool, dry place;

expires in 1 month Prepared formula: keep in sealed container in fridge; expires in 24 hr

Formula Hang times- 4 hr

Maintain Quality Control

Formula preparation Measure powders by weight

May need to use scoop provided in can if no scale available Verify formulations for accuracy and appropriateness

Labeling of prepared formulas Patient identifiers Formula name, concentration, volume Expiration date and time Check label against the order

Do you really need a specialized formula?What if you do not have one available?

Standard Polymeric Formulas

Standard Formula

Polymeric formula – intact proteinEnergy Density

Infant formulas- 20 kcal/oz Pediatric/Adult formula- 30 kcal/oz

Micronutrients Needs generally met by 1-1.5 L of formula

Water ~80-85% free water

Renal Formulas

Varying amounts of proteinLower/Absent Electrolytes (Na, Ca, K, Mg, Phos)Fluid restricted (1.8-2 kcal/ml)

Renal Disease

Considerations: Stage of disease and access to dialysis Access to sodium polystyrene sulfonate

Acute Risks: Heart arrhythmias from high potassium (K) Pulmonary edema or congestive heart failure from

excessive fluid Acute event from hypertension

Possible short-term substitute for renal formula: ?May not be able to tolerate any volume (no formula) ?Standard formula at a reduced volume to limit Na, K and fluid Make up calories and protein with K-free modulars

Always discuss your plan with medical team! Conditions may be much more complex than perceived

Hepatic Disease

BCAA-enriched formulas not indicated Specialized formula not indicated

Formulas for Diabetes

Lower % CHO (~35% of kcal)Higher % FatComplex carbohydrates (including more fiber)

Diabetes

Acute Risk: Hyperglycemia/Increased Infection Risk

Short-term substitute for diabetes formula: ?Standard formula at appropriate kcal level Communicate with physicians and nurses about

frequent blood glucose checks and insulin coverage

Pulmonary Disease

Chronic Obstructive Pulmonary Disease Risk: Overfeeding leads to increased CO2

production Specialized formula not indicated Do not provide excess kcal

Free Amino Acid Formulas

Used for Allergies or Severely Impaired GI Function for Infants, Older Children and Adults

Allergy

Considerations Be sure that lactose intolerance is not being confused

for milk protein allergy Most formulas are lactose-free, gluten-free

Risk: AnaphylaxisGoal: To obtain a formula free of allergen

Safest choice for milk or soy allergies or multiple protein allergies is free amino acid formula

Peptide-based with MCT oil

Often selected in cases of malabsorptionPartially hydrolyzed proteinHigher % MCT oil

Impaired GI tract/Malabsorption

Considerations: Degree of GI impairment Access to pancreatic enzymes if needed

Acute Risk: Increased stool output/dehydration

Short-term substitution: ?Standard formula run continuously at slow rate with

consideration of fluid and potassium losses

If severe GI impairment, may need supplemental TPN if using standard formula

Wounds

Ensure adequate kcal, protein and vitamin/mineral status (especially Vitamins A,C,E, and Zinc)

Specialized formula not indicated

Pediatric (>1 yr old)

Considerations: Adult formulas often contain higher levels of the following:

Protein- risk for dehydration Vitamin A Iron Electrolytes (Na, K) Magnesium Folic Acid Zinc

Acute Risk: Dehydration; consider extra fluid for high protein (see deployment guide p. 6)

Note: concentrated infant formula (30 kcal/oz) may also be appropriate for toddlers

Modulars

Extra calories Vegetable oil- monitor for separation; consider giving

as bolus Cornstarch

Extra protein Powdered milk- be sure to mix very well to avoid

clogging tube Pasteurized egg whites

Case Study 1

57 yr old male with chronic renal diseaseAccompanied by his wife who is a better historian

Has a history of poor intake and has G-tube Receives bolus of 1 can Nepro, 2-3 x/day + oral snacks Usually gets hemodialysis M/W/F, but missed Fri (now Mon) Pt has small amount of urine output still Has not gotten tube feeds in 5 days; eating potato chips,

granola bars- made him thirsty to drinking 1-2 20 oz water bottles/day

Social worker trying to arrange dialysis for tomorrow

No labs availableO2 saturations are low 90’sFMS cache has Glucerna and Ensure available

Case 1

What are the major considerations? Pt has been having minimal intake for 5 days Potassium likely elevated Fluid overload Dangerously high blood pressure?

What do you recommend right now? No more fluid until dialysis Consumption of only low Na and low K foods Initiate a plan to obtain a renal formula comparable to

Nepro Discuss plan with physician

Case 1

Later that week, patient is able to start regular dialysis

What are new recommendations? Liberalize fluid and electrolyte intake somewhat, but continue to

limit them Try to provide adequate kcal and protein

Implementation Provide standard formula in amount that would provide similar

potassium as 3 cans of Nepro (his usual intake while on dialysis) Depending on oral intake, could add vegetable oil to meet kcal

goal. Skim milk powder contains K so would not be a good way to meet protein goal.

Explain/discuss rationale of plan with physician

Case Study 2

5 yr old female with baseline neurologic impairment

Per mother Wt= 34 lb (15.4 kg) Usually gets continuous feeds of Pediasure at 45 ml/hr

x 22 hr via G-tube; never eats by mouth Has been growing well on this regiment Mother brought Pediasure from home, but it went

missing at last shelter

FMS cache has only powdered infant formula or RTF Boost

Case 2

Determine needs (using deployment guide) Use usual intake as kcal goal because she grew well

on that amount 1) 45 ml/hr x 22 hr = 990 ml 2) Pediasure is 30 kcal/oz (1kcal/ml), so 990 ml = 990

kcal Determine fluid needs

50-60 ml/kg 924 ml/day (using higher end of range) Determine protein needs

RDA=0.95 g/kg 15 g/day

Case 2

What formula to use? Infant formula

Powdered- requires preparation Would provide appropriate protein, but low levels of

some vit/min Adult standard formula

RTF- safer Provides excess amount of protein and some vit/min

Choose the RTF and provide extra fluid to compensate for excess protein

Case 2

Calculate fluid needs: 1) Usual needs = 925 ml/day 2) Extra fluid to compensate for extra protein

990 ml Boost provides 41 g protein = 2.7 g/ kgExtra fluid need=[(g protein/day)–(wt x 2.5 g/kg)] x 16

ml = 40 ml extra3) Total needs = 965 ml/day

Calculate free water intake: Most 30 kcal/oz formulas are ~80-85% free water

990 ml formula x 83% =820 ml free water from formula

Fluid deficit: 965 ml-820 ml= 145 mlDivide 145 ml into 6 G-tube flushes of 25 ml

Resources

The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach- The Adult Patient, 2007

The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum, 2010 Infant Feeding: Guidelines for Preparation of Human Milk and Formula in

Health Care Facilities, 2nd Edition, Pediatric Nutrition Practice Group, American Dietetic Association, 2011

Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. JPEN. 33 (3), 2009 p 277-316.

Malone, A. Successful management of enteral feeding. In: Current Concepts in Adult Critical Care, E.Y. Cheng and P.K. Park, eds. Society of Critical Care Medicine: 2012.

Malone, A. Enteral Formula Selection: A review of selected product categories. Practical Gastroenterology, June, 2005.

Bankhead et al. Enteral Nutrition Practice Recommendations. JPEN 33(2), 2009.

Thank you

Category Day Organizing CommitteeCDR Kathleen EdelmanCDR Blakeley FitzpatrickLCDR Merel KozloskyCDR Pamella VodickaCDR Sara Bergerson (retired)

Addendum:Sampling of Currently Marketed

Specialized Formulas not Already Discussed

Note: Formulas within a category are not necessarily interchangeable.

Calorically Dense Pediatric Formulas

Consider extra free water needs if not volume-restricted

Isotonic w/ or w/o Fiber

Isotonic formulas may be better toleratedGood choice for initiating feeds

Immune Enhancing

Not safe for use in the critically ill

Infant Formulas- Standard

Standard dilution = 20 kcal/oz

Infant Formulas-Soy

Lactose intolerance or galactosemia or vegan

Infant Formulas- Hydrolyzed Proteins

Mild allergies? or Malabsorption

Toddler Formulas

Marketed to bridge nutrient gap during transition to table foods

Modulars