introduction to enteral nutrition. enteral nutrition n nutrition delivered via the gut n includes...

Introduction to Enteral NutritionIntroduction to Enteral Nutrition

Enteral NutritionEnteral Nutrition

Nutrition delivered via the gut

Includes oral feedings and tube feedings

Nutrition delivered via the gut

Includes oral feedings and tube feedings

Enteral Tube FeedingEnteral Tube Feeding

Nutritional support via tube placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)

—Must have functioning GI tract

—IF THE GUT WORKS, USE IT!

—Exhaust all oral diet methods first.

Nutritional support via tube placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)

—Must have functioning GI tract

—IF THE GUT WORKS, USE IT!

—Exhaust all oral diet methods first.

Oral SupplementsOral Supplements

Between meals

Added to foods

Added into liquids for medication pass by nursing

Enhances otherwise poor intake

May be needed by children or teens to support growth

Between meals

Added to foods

Added into liquids for medication pass by nursing

Enhances otherwise poor intake

May be needed by children or teens to support growth

Copyright © 2000 by W. B. Saunders Company. All rights reserved.

Diagram of enteral tube placement.Diagram of enteral tube placement.

Fig. 22-2. p. 468.Fig. 22-2. p. 468.

Conditions That Require SpecializedNutrition SupportConditions That Require SpecializedNutrition Support

Enteral

—Impaired ingestion

—Inability to consume adequate nutrition orally

—Impaired digestion, absorption, metabolism

—Severe wasting or depressed growth Parenteral

—Gastrointestinal incompetency

—Hypermetabolic state with poor enteral tolerance or accessibility

Enteral

—Impaired ingestion

—Inability to consume adequate nutrition orally

—Impaired digestion, absorption, metabolism

—Severe wasting or depressed growth Parenteral

—Gastrointestinal incompetency

—Hypermetabolic state with poor enteral tolerance or accessibility

Algorithm for Decisions Algorithm for Decisions

Modified and adapted from Gorman RC, Morris JB: Minimally invasive access to the gastrointestinal tract. In Rombeau JL, Rolandelli RH, editors: Clinical nutrition: enteral and tube feeding, p 174, Philadelphia, 1997, WB Saunders; and Ali A et al:Nutritional support services, Nutritional Support Algorithms, 8(7):13, July 1998.

Indications for Enteral Nutrition Indications for Enteral Nutrition

Malnourished patient expected to be unable to eat >5-7 days

Normally nourished patient expected to be unable to eat >7-9 days

Adaptive phase of short bowel syndrome Increased needs that cannot be met

through oral intake (burns, trauma) Inadequate oral intake resulting in

deterioration of nutritional status or delayed recovery from illness

Malnourished patient expected to be unable to eat >5-7 days

Normally nourished patient expected to be unable to eat >7-9 days

Adaptive phase of short bowel syndrome Increased needs that cannot be met

through oral intake (burns, trauma) Inadequate oral intake resulting in

deterioration of nutritional status or delayed recovery from illness

ASPEN. The science and practice of nutrition support. A case-Based Core curriculum. 2001; 143

Contraindications for ENContraindications for EN

Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted

Severe acute pancreatitis High output proximal fistula Inability to gain access Intractable vomiting or diarrhea Aggressive therapy not warranted

ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143

Contraindications for ENContraindications for EN

Inadequate resuscitation or hypotension; hemodynamic instability

Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if

malnourished or 7-9 days if normally nourished

Inadequate resuscitation or hypotension; hemodynamic instability

Ileus Intestinal obstruction Severe G.I. Bleed Expected need less than 5-7 days if

malnourished or 7-9 days if normally nourished

Advantages - Enteral vs PNAdvantages - Enteral vs PN

Preserves gut integrity

Possibly decreases bacterial translocation

Preserves immunological function of gut

Reduces costs (EAL Grade II)

Fewer infectious complications in critically ill patients (EAL Grade I)

Safer and more cost effective in many settings

Preserves gut integrity

Possibly decreases bacterial translocation

Preserves immunological function of gut

Reduces costs (EAL Grade II)

Fewer infectious complications in critically ill patients (EAL Grade I)

Safer and more cost effective in many settingsASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 147

ADA EAL, Critical Illness, accessed 8-07

Advantages—Enteral NutritionAdvantages—Enteral Nutrition

Intake easily/accurately monitored

Provides nutrition when oral is not possible or adequate

Supplies readily available

Reduces risks associated with disease state

Intake easily/accurately monitored

Provides nutrition when oral is not possible or adequate

Supplies readily available

Reduces risks associated with disease state

Disadvantages—Enteral NutritionDisadvantages—Enteral Nutrition

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

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

Enteral FormulasEnteral Formulas

Liquid diets intended for oral use or for tube feeding

Ready-to-use or powdered form

Designed to meet variety of medical and nutrition needs

Can be used alone or given with foods

Liquid diets intended for oral use or for tube feeding

Ready-to-use or powdered form

Designed to meet variety of medical and nutrition needs

Can be used alone or given with foods

Formula SelectionFormula SelectionThe suitability of a feeding formula should be evaluated based on The suitability of a feeding formula should be evaluated based on

Functional status of GI tract

Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)

Macronutrient ratios

Digestion and absorption capability of patient

Specific metabolic needs

Contribution of the feeding to fluid and electrolyte needs or restriction

Cost effectiveness

Functional status of GI tract

Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)

Macronutrient ratios

Digestion and absorption capability of patient

Specific metabolic needs

Contribution of the feeding to fluid and electrolyte needs or restriction

Cost effectiveness


Determine best choice by medical and nutrition assessment

Meet specific nutrition needs

Determine best choice by medical and nutrition assessment

Meet specific nutrition needs


Complete formulas:

– Enteral formulas designed to supply all needed nutrients when given in sufficient volume

– May also be used in smaller quantities to supplement regular diets

Complete formulas:

– Enteral formulas designed to supply all needed nutrients when given in sufficient volume

– May also be used in smaller quantities to supplement regular diets

Enteral Formula CategoriesEnteral Formula Categories

Polymeric

Monomeric

Fiber-containing

Disease-specific

Rehydration

Modular

Polymeric

Monomeric

Fiber-containing

Disease-specific

Rehydration

Modular

Enteral Formula CategoriesPolymericEnteral Formula CategoriesPolymeric

Whole protein nitrogen source

For use in patients with normal or near normal GI function

– Protein isolate formulas– Protein that has been separated from a food (casein

from milk, albumin from egg)

– Blenderized formulas

• May contain pureed meat, vegetables, fruits, milk, starches with v/m added

• Made at home or purchased commercially

Whole protein nitrogen source

For use in patients with normal or near normal GI function

– Protein isolate formulas– Protein that has been separated from a food (casein

from milk, albumin from egg)

– Blenderized formulas

• May contain pureed meat, vegetables, fruits, milk, starches with v/m added

• Made at home or purchased commercially

Enteral Formula CategoriesPolymericEnteral Formula CategoriesPolymeric

Enteral Formula CategoriesMonomericEnteral Formula CategoriesMonomeric

Elemental/hydrolyzed

Predigested nutrients

Free amino acids and/or short peptide chains

Has low fat content or high percentage of MCT, LCT, structured lipids

Elemental/hydrolyzed

Predigested nutrients

Free amino acids and/or short peptide chains

Has low fat content or high percentage of MCT, LCT, structured lipids


Use in patients with compromised digestive and/or absorptive capacity

More expensive than standard formulas

Tend to be more hyperosmolar because of small particle size

Use in patients with compromised digestive and/or absorptive capacity

More expensive than standard formulas

Tend to be more hyperosmolar because of small particle size

Enteral Formula CategoriesFiber-ContainingEnteral Formula CategoriesFiber-Containing

Fiber-containing: containing a source of fiber; reportedly beneficial for prevention/treatment of altered bowel function in enterally fed patients

Soy polysaccharide is the most common fiber additive in enteral feedings; effectiveness in treating diarrhea in tubefed patients unproven

Fiber-containing: containing a source of fiber; reportedly beneficial for prevention/treatment of altered bowel function in enterally fed patients

Soy polysaccharide is the most common fiber additive in enteral feedings; effectiveness in treating diarrhea in tubefed patients unproven


Enteral Formula CategoriesFiber-ContainingEnteral Formula CategoriesFiber-Containing Soluble fiber (guar gum, oat fiber, pectin) may

exert trophic effect on colonic mucosa and be useful in normalizing bowel function

Most enteral feedings in amounts typically used contain less than recommended fiber intake for adults (20-35 g)

Patients with impaired gastric emptying should not be fed fiber-containing formula into the stomach

Soluble fiber (guar gum, oat fiber, pectin) may exert trophic effect on colonic mucosa and be useful in normalizing bowel function

Most enteral feedings in amounts typically used contain less than recommended fiber intake for adults (20-35 g)

Patients with impaired gastric emptying should not be fed fiber-containing formula into the stomach


Enteral Formula CategoriesFiber-ContainingEnteral Formula CategoriesFiber-Containing

Enteral Formulas: Calorie DenseEnteral Formulas: Calorie Dense

May be used in fluid-restricted or volume-sensitive patients

Useful for nocturnal feedings where nutrition must be delivered over brief time span

Calorie density ranges from 1.3 to 2 kcals/ml

Monitor fluid/hydration status

May be used in fluid-restricted or volume-sensitive patients

Useful for nocturnal feedings where nutrition must be delivered over brief time span

Calorie density ranges from 1.3 to 2 kcals/ml

Monitor fluid/hydration status

Enteral Formulas: Calorie DenseEnteral Formulas: Calorie Dense

Enteral Formula CategoriesDisease SpecificEnteral Formula CategoriesDisease Specific

Designed for patients with specific disease states.

Available for patients with respiratory disease, ARDS, diabetes, renal failure, hepatic failure, and immune compromise.

Well-designed clinical trials may or may not be available (mostly not)

Many of the trials have been done with formula “cocktails,” making it difficult to identify the operative variable

Designed for patients with specific disease states.

Available for patients with respiratory disease, ARDS, diabetes, renal failure, hepatic failure, and immune compromise.

Well-designed clinical trials may or may not be available (mostly not)

Many of the trials have been done with formula “cocktails,” making it difficult to identify the operative variable


Pharmaceutical effects are claimed for many specialty enteral formulas (reduced LOS, reduced infections, reduced time on the ventilator)

Mfrs are charging pharmaceutical prices (8-10 times more expensive than standard)

Enteral formulas are classed as medical foods, not drugs and are regulated differently

Pharmaceutical effects are claimed for many specialty enteral formulas (reduced LOS, reduced infections, reduced time on the ventilator)

Mfrs are charging pharmaceutical prices (8-10 times more expensive than standard)

Enteral formulas are classed as medical foods, not drugs and are regulated differently


The FDA does not evaluate adult medical foods before they go on the market

The government does not require that mfrs prove that formulas are safe and effective or that claims are valid

FDA requires that formula mfrs use good manufacturing practices and that products are accurately labeled

It is up to the clinician to evaluate the evidence that supports the claims regarding medical foods

The FDA does not evaluate adult medical foods before they go on the market

The government does not require that mfrs prove that formulas are safe and effective or that claims are valid

FDA requires that formula mfrs use good manufacturing practices and that products are accurately labeled

It is up to the clinician to evaluate the evidence that supports the claims regarding medical foods

Considerations in Evaluating Specialized Enteral FormulasConsiderations in Evaluating Specialized Enteral Formulas

Is the nutrient profile appropriate based on the known metabolic needs and nutrient requirements of the condition

Are there prospective double-blind RCTs to support claims (not case reports)

Data obtained using animal models may have limited application to humans

Product-specific research applies to that product only

Is the nutrient profile appropriate based on the known metabolic needs and nutrient requirements of the condition

Are there prospective double-blind RCTs to support claims (not case reports)

Data obtained using animal models may have limited application to humans

Product-specific research applies to that product only

Enteral FormulasEvaluating the ResearchEnteral FormulasEvaluating the Research

Research cannot always be generalized to a different population (studies in burn patients to trauma pts)

Were the endpoints clinically significant (a biochemical marker only or important clinical outcome such as wound healing)?

Who funded the study?

Has the work been replicated?

Research cannot always be generalized to a different population (studies in burn patients to trauma pts)

Were the endpoints clinically significant (a biochemical marker only or important clinical outcome such as wound healing)?

Who funded the study?

Has the work been replicated?

Disease Specific FormulasDiabeticDisease Specific FormulasDiabetic

Amount and type of CHO modified to reduce blood glucose response

Increased fat content (may have increased monounsaturated fats)

Results of studies using these formulas have been mixed

Most standard enteral formulas fall within American Diabetes Association guidelines for macronutrient mix

Amount and type of CHO modified to reduce blood glucose response

Increased fat content (may have increased monounsaturated fats)

Results of studies using these formulas have been mixed

Most standard enteral formulas fall within American Diabetes Association guidelines for macronutrient mix

Disease Specific FormulasDiabeticDisease Specific FormulasDiabetic

Blood glucose control in acute care is often affected by illness, infection, other issues

Patients on enteral feedings generally receive a more consistent CHO intake than persons on oral diets

May be worth trying diabetes formulas in patients who have failed to achieve good blood glucose control on standard formulas

Blood glucose control in acute care is often affected by illness, infection, other issues

Patients on enteral feedings generally receive a more consistent CHO intake than persons on oral diets

May be worth trying diabetes formulas in patients who have failed to achieve good blood glucose control on standard formulas

Disease Specific Formulas: DiabeticDisease Specific Formulas: Diabetic

Disease Specific FormulasHepaticDisease Specific FormulasHepatic

Generally have reduced aromatic amino acids and increased branched chain amino acids

More expensive than standard products

Often lower in protein than standard formulas (may be too low for most liver patients)

Research using these products has been inconclusive

Standard (high protein) products are generally appropriate for patients with liver disease

Generally have reduced aromatic amino acids and increased branched chain amino acids

More expensive than standard products

Often lower in protein than standard formulas (may be too low for most liver patients)

Research using these products has been inconclusive

Standard (high protein) products are generally appropriate for patients with liver disease

Disease Specific FormulasRenalDisease Specific FormulasRenal

Originally developed in an effort to delay the need for dialysis as long as possible

Typically are calorie dense (2.0 kcal/cc) products with relatively low protein levels and modified electrolytes

Generally too low in protein for dialyzed patients and acutely ill patients

May be useful for short term use as supplement or calorie source in pre-dialysis chronic renal failure patients

Originally developed in an effort to delay the need for dialysis as long as possible

Typically are calorie dense (2.0 kcal/cc) products with relatively low protein levels and modified electrolytes

Generally too low in protein for dialyzed patients and acutely ill patients

May be useful for short term use as supplement or calorie source in pre-dialysis chronic renal failure patients

Disease-Specific Formulas RenalDisease-Specific Formulas Renal

Novasource Renal

Disease Specific FormulasImmune-EnhancingDisease Specific FormulasImmune-Enhancing

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

Meta-analysis suggests that they might be most beneficial in surgical patients

Some evidence of harm in septic patients

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

Meta-analysis suggests that they might be most beneficial in surgical patients

Some evidence of harm in septic patients

Immune-Enhancing EN in Critical Care: ADA Evidence-Based GuidelinesImmune-Enhancing EN in Critical Care: ADA Evidence-Based Guidelines

R.3 Immune-enhancing EN is not recommended for routine use in critically ill patients in the ICU.

Immune-enhancing EN is not associated with reduced infectious complications, LOS, reduced cost of medical care, days on mechanical ventilation or mortality in moderately to less severely ill ICU patients.

Their use may be associated with increased mortality in severely ill ICU patients, although adequately-powered trials evaluating this have not been conducted.

Strength: Fair; imperative

R.3 Immune-enhancing EN is not recommended for routine use in critically ill patients in the ICU.

Immune-enhancing EN is not associated with reduced infectious complications, LOS, reduced cost of medical care, days on mechanical ventilation or mortality in moderately to less severely ill ICU patients.

Their use may be associated with increased mortality in severely ill ICU patients, although adequately-powered trials evaluating this have not been conducted.

Strength: Fair; imperative

Immune-Enhancing EN in Critical Care: ADA Evidence-Based GuidelinesImmune-Enhancing EN in Critical Care: ADA Evidence-Based Guidelines

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.

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.

Source: ADA EAL Evidence-Based Guidelines, accessed 8/07

Immune-Enhancing FormulasImmune-Enhancing Formulas

Disease-Specific FormulaPulmonaryDisease-Specific FormulaPulmonary

Contain higher percentage of total calories from fat to reduce respiratory quotient and make it easier to wean from respirator

However, total calorie intake has more impact on respiratory function than formula composition

There is a lack of clinical trials demonstrating a clear benefit

High fat gastric feedings may cause delayed emptying in critically ill patients

Contain higher percentage of total calories from fat to reduce respiratory quotient and make it easier to wean from respirator

However, total calorie intake has more impact on respiratory function than formula composition

There is a lack of clinical trials demonstrating a clear benefit

High fat gastric feedings may cause delayed emptying in critically ill patients

Disease-Specific Formulas: PulmonaryDisease-Specific Formulas: Pulmonary

Enteral Formula CategoriesRehydration and ModularEnteral Formula CategoriesRehydration and Modular

Rehydration: for patients requiring optimal ratio of carbohydrate to electrolytes to facilitate fluid and electrolyte absorption, rehydration

Modular: provides protein, fat, or carbohydrate as single nutrients or modular mixtures to allow adjustment of macronutrient mix. May also contribute to renal solute load, osmolality

Rehydration: for patients requiring optimal ratio of carbohydrate to electrolytes to facilitate fluid and electrolyte absorption, rehydration

Modular: provides protein, fat, or carbohydrate as single nutrients or modular mixtures to allow adjustment of macronutrient mix. May also contribute to renal solute load, osmolality

Enteral Formula CategoriesModularEnteral Formula CategoriesModular

Enteral Formula Nutrient SourcesCarbohydrateEnteral Formula Nutrient SourcesCarbohydrate

CHO content ranges from 40-90% of total calories

Typically some combination of hydrolyzed cornstarch, maltodextrins, corn syrup solids, sucrose

FOS: fructooligosaccharides; poorly absorbed in the small intestine, fermented in the large intestine; may promote growth of healthy bacteria

Fiber: soy polysaccharide (most common) guar gum, oat fiber, pectin

CHO content ranges from 40-90% of total calories

Typically some combination of hydrolyzed cornstarch, maltodextrins, corn syrup solids, sucrose

FOS: fructooligosaccharides; poorly absorbed in the small intestine, fermented in the large intestine; may promote growth of healthy bacteria

Fiber: soy polysaccharide (most common) guar gum, oat fiber, pectin

Enteral Formula Nutrient SourcesLipidsEnteral Formula Nutrient SourcesLipids

Fat provides isotonic, concentrated energy source

Corn and soybean oil common

Also safflower, canola, fish oil

May include MCTs; more easily digested and absorbed

Fat content ranges from <10% to >50% of calories

Fat provides isotonic, concentrated energy source

Corn and soybean oil common

Also safflower, canola, fish oil

May include MCTs; more easily digested and absorbed

Fat content ranges from <10% to >50% of calories


Enteral Formulas Nutrient SourcesProteinEnteral Formulas Nutrient SourcesProtein

Whole protein, hydrolyzed protein, free amino acids

Casein, soy protein, lactalbumin, whey, egg white albumin

Small peptides absorbed as efficiently as free amino acids

Free amino acids are more hyperosmolar

Whole protein, hydrolyzed protein, free amino acids

Casein, soy protein, lactalbumin, whey, egg white albumin

Small peptides absorbed as efficiently as free amino acids

Free amino acids are more hyperosmolar

Enteral Formulas Nutrient SourcesProteinEnteral Formulas Nutrient SourcesProtein

Arginine: conditionally essential amino acid with immune-enhancing properties. Research suggests some benefit in wound healing (rat studies and biochemical changes.) Recent research suggests may be harmful in septic patients

Glutamine: may enhance small intestine growth and repair; however, available research done with parenteral glutamine; enteral delivery not well studied

Arginine: conditionally essential amino acid with immune-enhancing properties. Research suggests some benefit in wound healing (rat studies and biochemical changes.) Recent research suggests may be harmful in septic patients

Glutamine: may enhance small intestine growth and repair; however, available research done with parenteral glutamine; enteral delivery not well studied

Enteral Formulas: Nutrient SourcesProteinEnteral Formulas: Nutrient SourcesProtein

Branched-Chain Amino Acids: evaluated in critical care and liver failure patients in the 70s and 80s

Thought to prevent or treat hepatic encephalopathy and prevent muscle catabolism

Studies using BCAA have been inconclusive

Effectiveness of therapy cannot be evaluated based on current research

BCAA sometimes recommended for refactory encephalopathy

Branched-Chain Amino Acids: evaluated in critical care and liver failure patients in the 70s and 80s

Thought to prevent or treat hepatic encephalopathy and prevent muscle catabolism

Studies using BCAA have been inconclusive

Effectiveness of therapy cannot be evaluated based on current research

BCAA sometimes recommended for refactory encephalopathy

Establishing an Enteral FormularyEstablishing an Enteral Formulary

Many health care organizations find it cost-effective to establish an enteral formulary based on clinical effectiveness and cost

The health care organization or management company may purchase from one company or several

Many health care organizations find it cost-effective to establish an enteral formulary based on clinical effectiveness and cost

The health care organization or management company may purchase from one company or several


Evaluate common diagnoses of patients on enteral formulas and the formulas most often used in the past year

Identify categories of formulas that fill a need, such as standard 1 kcal/cc formula; standard 1 kcal/cc high protein formula; calorie dense formula (1.5 or 2.0 calories/cc); fiber-containing, monomeric, etc.

Write generic specifications for each product category

Evaluate common diagnoses of patients on enteral formulas and the formulas most often used in the past year

Identify categories of formulas that fill a need, such as standard 1 kcal/cc formula; standard 1 kcal/cc high protein formula; calorie dense formula (1.5 or 2.0 calories/cc); fiber-containing, monomeric, etc.

Write generic specifications for each product category


Identify commercially available products that fit into each category

Where several formulas fit, choose based on cost, service, available packaging (closed vs open system)

Identify commercially available products that fit into each category

Where several formulas fit, choose based on cost, service, available packaging (closed vs open system)

Open vs Closed SystemOpen vs Closed System

Open SystemOpen System

Product is decanted into a feeding bag

Allows modulars such as protein and fiber to be added to feeding formulas

Less waste in unstable patients (maybe)

Shortens hang time

Increases nursing time

Increased risk of contamination

Product is decanted into a feeding bag

Allows modulars such as protein and fiber to be added to feeding formulas

Less waste in unstable patients (maybe)

Shortens hang time

Increases nursing time

Increased risk of contamination

Closed System or Ready to HangClosed System or Ready to Hang

Containers sterile until spiked for hanging

Can be used for continuous or bolus delivery

No flexibility in formula additives

Less nursing time

Increases safe hang time

Less risk of contamination

More expensive than canned formula

Containers sterile until spiked for hanging

Can be used for continuous or bolus delivery

No flexibility in formula additives

Less nursing time

Increases safe hang time

Less risk of contamination

More expensive than canned formula

Closed vs Open SystemClosed vs Open System

Open System

Hang time 8 hours for decanted formula; 4 hours for formula mixtures

Feeding bag and tubing should be rinsed each time formula replenished

Contaminated feedings are associated with pt morbidity

Open System

Hang time 8 hours for decanted formula; 4 hours for formula mixtures

Feeding bag and tubing should be rinsed each time formula replenished

Contaminated feedings are associated with pt morbidity

Closed System

Hang time 24-48 hours based on mfr recommendations

Y port can be used to deliver additional fluid and modulars

May result in less formula waste as open system formula should be discarded p 8 hours

Closed System

Hang time 24-48 hours based on mfr recommendations

Y port can be used to deliver additional fluid and modulars

May result in less formula waste as open system formula should be discarded p 8 hours

Closed vs Open SystemClosed vs Open System In a survey of nurses at MetroHealth, only 28%

were aware of the 8 hour hang time for open system formulas written into nursing policy

55% recommended adding new formula to old, in violation of existing nursing protocol

66% could state the 24 hang time for closed system formulas

The cost of wasted formula is minimal compared to the cost of nursing time and risk of illness in patients

In a survey of nurses at MetroHealth, only 28% were aware of the 8 hour hang time for open system formulas written into nursing policy

55% recommended adding new formula to old, in violation of existing nursing protocol

66% could state the 24 hang time for closed system formulas

The cost of wasted formula is minimal compared to the cost of nursing time and risk of illness in patients

Luther H, Barco K, Chima CS, Yowler CJ. Comparative study of two systems of delivering supplemental protein with standardized tube feedings. J Burn Care Rehabil 2003;24:167-172.

F i g u r e 1 . T o ta l d a i ly n u r s in g t im e p r o te in b o lu s v s o p e n s y s t e m

1 8 .6

3 6 .6

0

5

1 0

1 5

2 0

2 5

3 0

3 5

4 0

O p e n S y s te m C l o se d S y s t e m / P r o te i nF l u s h

M i n u te s / d a y

N = 5 ; P = .0 5

Nursing Time Open vs Closed System (MetroHealth)Nursing Time Open vs Closed System (MetroHealth)

Luther H, Barco K, Chima CS, Yowler CJ. J Burn Care Rehabil 2003;24:167-172.

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