3: Enteral Nutrition Overview

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Questions and Answers

What is a primary benefit of enteral nutrition?

Complete avoidance of infection

Preservation of GI mucosal integrity (correct)

Immediate nutrient absorption

Increased appetite

Which condition would necessitate the use of enteral nutrition due to the inability to eat orally?

Routine dietary preferences

Normal digestive function

Dysphagia due to neurological disorders (correct)

Increased appetite during recovery

In what scenario should enteral nutrition be prioritized over parenteral nutrition?

When the gut is functional (correct)

In cases of complete food refusal

When oral intake is sufficient

When there is no functional GI tract

Which of the following is NOT a potential indication for enteral nutrition?

Normal digestive capability Signup and view all the answers

What does the phrase 'if the gut works, use it' imply in the context of nutritional support?

Enteral nutrition is preferred if the GI tract is functioning Signup and view all the answers

Which situation is classified as an impaired intake condition for enteral nutrition?

Traumatic brain injury Signup and view all the answers

Which of the following conditions would allow for enteral nutrition despite a mechanical obstruction?

Proximal obstruction of the GI tract Signup and view all the answers

What is a potential result of enteral nutrition regarding the body's response?

Attenuation of the metabolic rate Signup and view all the answers

What is a common source of carbohydrates in enteral formulas?

Sucrose Signup and view all the answers

Which type of fiber is thought to improve bowel function in enteral formulas?

Soluble fiber Signup and view all the answers

What type of protein is typically found in standard enteral formulas?

Intact protein Signup and view all the answers

Which type of lipids are more readily absorbed in enteral formulas?

Medium-chain triglycerides (MCTs) Signup and view all the answers

What type of formulas contain di- and tri-peptides and amino acids?

Elemental formulas Signup and view all the answers

Fructooligosaccharides are primarily used as what type of ingredient in enteral formulas?

Prebiotics Signup and view all the answers

Which type of formulations typically do NOT require bile salts or pancreatic lipase for digestion?

MCT-based formulas Signup and view all the answers

What is the main function of structured lipids in enteral formulas?

Improve absorption Signup and view all the answers

Which of the following is a potential complication of nasogastric tube (NGT) placement?

Esophageal strictures Signup and view all the answers

What is the method involved in placing a percutaneous endoscopic gastrostomy (PEG) tube?

Using an endoscope and local anesthesia Signup and view all the answers

Which statement is true regarding the placement of surgical gastrostomy (G-tube)?

The patient is sedated during the procedure Signup and view all the answers

A significant risk associated with incorrect positioning of a nasogastric tube is:

Aspiration pneumonia Signup and view all the answers

What is a common method for providing long-term nutritional support?

Percutaneous endoscopic jejunostomy (PEJ) Signup and view all the answers

Which of the following complications is specifically related to mucosal injury from NGT?

Nasal erosion Signup and view all the answers

Ruptured gastroesophageal varices is a potential complication seen in which condition?

Hepatic disease Signup and view all the answers

What is an advantage of PEG tube placement over surgical gastrostomy?

Minimally invasive with limited anesthesia Signup and view all the answers

What is the primary characteristic of polymeric formulas?

They contain intact macronutrients. Signup and view all the answers

Which of the following is true about monomeric formulas?

They are indicated for patients with gastrointestinal compromise. Signup and view all the answers

What is the caloric density for standard intact polymeric formulas?

1-2 kcal/mL Signup and view all the answers

Which characteristic does NOT describe hydrolyzed formulas?

They contain intact macronutrients. Signup and view all the answers

What is the osmolarity characteristic of standard intact polymeric formulas?

Isotonic at 300-500 mOsm/kg Signup and view all the answers

Which factor can lead to the selection of concentrated formulas in enteral feeding?

Requirement for fluid restriction. Signup and view all the answers

Which of the following enteral formulas is an example of a polymeric formula?

Osmolite (Abbott) Signup and view all the answers

What is a key feature of disease-specific formulas?

They are tailored for particular medical conditions. Signup and view all the answers

What is the primary purpose of using modulars in nutritional formulas?

To offer single nutrients for composition alteration Signup and view all the answers

Which of the following is true regarding diabetic formulas?

They can be difficult to show clinical benefits. Signup and view all the answers

What distinguishes renal formulas from standard nutritional formulas?

They have adjusted protein and electrolyte content. Signup and view all the answers

Which amino acids are increased in hepatic formulas?

Branched chain amino acids Signup and view all the answers

What is a possible challenge when using modulars in nutrient preparation?

Increased cost and labor for mixing Signup and view all the answers

What is the caloric density of renal formulas compared to standard formulas?

Higher than standard formulas Signup and view all the answers

What is the typical protein content in hepatic formulas?

Very low protein Signup and view all the answers

Which of the following products is an example of a modular?

ProSource Signup and view all the answers

Study Notes

Enteral Nutrition

Providing nutrients through the GI tract using a feeding tube
Suitable for those who can't meet their nutritional needs orally
- Including dysphagia, lethargy, altered mental status
- Requires a functioning GI tract
Consider EN after all attempts to increase oral intake
Prioritize EN over parenteral nutrition (PN) unless contraindicated
- "If the gut works, use it"
Consider factors like prognosis and ethical concerns

Benefits of Enteral Nutrition

Preserves GI mucosal integrity and immunologic functions
Attenuates catabolic response
Lower risk of infectious complications (controversial)

Indications for Enteral Nutrition

Inability to eat orally
- Neurological disorders causing dysphagia
- Facial, oral, or esophageal trauma
- Congenital anomalies
- Critical illness, mechanical ventilation
- Traumatic brain injury
- Altered mental status, comatose state
- Mechanical obstruction (depending on location, proximal obstruction)
- Disruption of the upper GI tract (head & neck surgery, esophagectomy)

Indications for Enteral Nutrition (Continued)

Inability to consume enough orally
- Hypermetabolic state
- Increased nutrient requirements
- Decreased appetite
- Impaired intake after orofacial surgery or injury
- Dementia, altered mental status
- Impaired digestion and/or malabsorption
- Short bowel syndrome
- Premature infants

Long Term Access

Percutaneous endoscopic gastrostomy (PEG) or Percutaneous endoscopic jejunostomy (PEJ) placement
- Nonsurgical techniques for placing a feeding tube directly into the stomach through the abdominal wall using an endoscope and local anesthesia
- Tubes are guided from the nose to the stomach or jejunum and brought out through the abdominal wall
- Short procedure time and limited anesthesia requirements
- Common method of feeding tube placement
- Refers to the placement method (procedure) and not the tube itself
- A PEG tube can be converted to a gastrojejunostomy by threading a small tube through the larger tube into the jejunum
Surgical gastrostomy (G-tube) or jejunostomy (J-tube) placement
- Feeding tube placed surgically while the patient is sedated

Multiple Purpose Gastrostomy

Gastric suction (decompression)
Jejunal feeding

Types and Categories of Enteral Formulas

Often classified based on protein or overall macronutrient composition
Three basic categories:
- Polymeric (intact)
- Monomeric (hydrolyzed, pre-digested)
- Disease-specific

Standard Intact

Polymeric formulas contain intact macronutrients and are intended for normal or near normal GI function
Typically provide 1-2 kcal/mL
- 1.5-2 kcal/mL concentrated formulas are useful when fluid restriction is required
300-500 mOsm/kg (Isotonic)
Lactose free
Least costly
Examples: Osmolite, Jevity, Nutren

Hydrolyzed

Indicated for patients with gastrointestinal compromise requiring hydrolyzed nutrients for improved digestion
Chemically defined, peptide-based, monomeric, elemental, or semi-elemental
Typically 1-1.2 kcal/mL
Lactose free
Low fat, MCT based
More expensive
Examples: Peptamen, Vivonex, Vital

Formula Content- Carbohydrates

CHO content varies from 30-85% of kcals
Sources: monosaccharides, oligosaccharides, dextrins, hydrolyzed corn starch, maltodextrins; corn syrup is typically used in standard formulas
- Sucrose is added to flavored formulas meant for oral consumption
- Hydrolyzed formulas contain cornstarch or maltodextrin
- All commercially available enteral formulas are lactose free
With or without added dietary fiber (both soluble and insoluble)
- Fiber-added formulas are thought to improve stool consistency
- Evidence for benefits of fiber-added formulas is mixed
- Improved bowel function is more often attributed to soluble fiber, but many enteral formulas contain lower amounts of soluble fiber (hydrophilic), which attracts water, causes the formula to thicken and form a gel
Fructooligosaccharides (prebiotics) may also be added (beneficial bacteria production)
- Use can contribute to undesirable GI symptoms (gas, bloating, diarrhea)

Formula Content- Lipid

Sources: corn, soy, safflower, canola, fish oils
Majority in the form of LCTs and MCTs, some structured lipids (LCT + MCT)
- Structured lipids are more readily absorbed and better tolerated
- Most of the LCTs in structured lipids are omega-3 fatty acids
- Elemental formulas are typically in MCT form, which do not require bile salts or pancreatic lipase for digestion and are absorbed directly into the portal circulation

Formula Content- Protein

Typically derived from whey, casein, or soy protein isolate
Standard formulas contain intact protein that requires enzymes to split the nutrient into peptides before absorption
Elemental formulas contain di- and tri-peptides and amino acids (hydrolyzed)
- Used for enzyme deficiency, malabsorption, etc

Formula Content- Vitamins, Minerals, Electrolytes

Most formulas meet the RDI for vitamins/minerals in average adults

Modulars

Provide protein, fat, or carbohydrate as single nutrients to alter the nutrient composition of commercial formulas or food
Examples: ProSource (protein, liquid), Beneprotein (protein), Benefiber (fiber), Benecalorie (protein/fat), Polycose (carbohydrate)
Increased costs
Increased labor for mixing
Potential for clumping, clogging of tubes

Diabetic Formulas

Lower in total carbohydrates and vary in type of carbohydrates
Added fiber: soluble and insoluble
Difficult to show clinical benefit with use of these formulas
May be appropriate to trial with difficult to control BG
Consider bolus vs continuous feeds
Examples: Glucerna, DiabetiSource AC

Renal Formulas

Formulas designed for patients with renal disease
Adjusted protein, electrolyte, fluid, vitamin, & mineral content compared to standard formulas
- Contain lower levels of potassium and phosphorus
- Concentrated (1.8kcal/kg)
- Examples: Nepro, Suprena (less protein)
End Stage Renal Disease (ESRD) on dialysis
- To meet higher protein needs, additional protein supplementation may be necessary (Beneprotein)
- In the absence of elevated potassium or phosphorus labs, it is preferable to continue with a standard high-protein formula

Hepatic Formulas

Calorically dense; total protein is usually very low
- Increased levels of BCAA (branched chain amino acids): valine, leucine, isoleucine
- Decreased levels of AAA (aromatic amino acids): phenylalanine, tyrosine, tryptophan
- Examples: NutriHep, Hepatic Aid

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Description

This quiz covers the fundamentals of enteral nutrition, including its indications, benefits, and considerations for patients unable to meet nutritional needs orally. From dysphagia to critical illness, learn when to prioritize enteral over parenteral nutrition and understand the importance of maintaining GI health.