Enteral Nutrition Lecture 3 Fall 2024 PDF

9/17/24 Enteral Nutrition L EC T U R E 3 – FA L L 2 0 2 4 1 1 Nutrition Support v Enteral Nutrition o Provision of nutrients into...

9/17/24 Enteral Nutrition L EC T U R E 3 – FA L L 2 0 2 4 1 1 Nutrition Support v Enteral Nutrition o Provision of nutrients into the stomach or intestines using a feeding tube § Indicated when oral intake is not possible or inadequate § To provide tube feeds the GI tract needs to be functional v Parenteral Nutrition o Provision of nutrients intravenously o Indicated when oral intake is not possible or inadequate and provision of enteral nutrition support (tube feeding) is not feasible 2 2 1  9/17/24 3 3 Nutrition Support v How do you decide when to provide enteral nutrition support? o First should exhaust all methods to try to increase oral intake § Increasing caloric density § Small frequent meals § Oral nutrition supplements § Appetite stimulants § Patient comprehension § Family support § Community support § Etc 4 4 2  9/17/24 Oral Supplements v Examples of oral nutrition supplements o Boost (Nestle), Ensure (Abbott) o Specialized: Glucerna (Diabetes), Nepro (Renal) o Clear Liquid: Ensure Clear, Boost Breeze o Pudding: Boost, Ensure o Modified Consistency (thickened): Magic Cup, Gelatein Plus/Gelatein 20 o Orgain (organic), Compleat (blenderized), Enu (meal replacement) o Plant-Based: Kate Farms, OWYN (vegan) o Modular –added to other products, foods, beverages Benecalorie Beneprotein Benefiber Prostat Polycose MCT oil 5 5 Enteral Nutrition v The provision of nutrients via the GI tract using a feeding tube v Recommended for those who are unable to meet nutrient requirements through oral intake o ie poor intake, dysphagia, lethargy, altered mental status o must still have functional GI tract v Once you’ve tried all attempts to increase oral intake v Should be considered before PN unless there is a contraindication o Rule of thumb: “if the gut works use it” v Consideration: Favorable prognosis/ethical dilemmas 6 6 3  9/17/24 Benefits of Enteral Nutrition v Preservation of o GI mucosal integrity o Mucosal immunologic functions v Attenuation of the catabolic response v Significantly lower risk for infectious complications* *Controversial 7 7 Indications for Enteral Nutrition v Inability to eat orally o Neurological disorders (dysphagia) o Facial, oral or esophageal trauma o Congenital anomalies o Critical illness, mechanical ventilation o Traumatic brain injury o Altered mental status; comatose state o Mechanical obstruction § depends on location; proximal obstruction o Disruption of upper GI tract § head & neck surgery, esophagectomy 8 8 4  9/17/24 Indications for Enteral Nutrition v Inability to consume enough orally o Hypermetabolic state o Increased nutrient requirements o Decreased appetite o Impaired intake after orofacial surgery or injury o Dementia, altered mental status v Impaired digestion, absorption, metabolism o Severe gastroparesis (j-tube) o Inborn errors of metabolism o Crohn’s disease (in certain instances) o Pancreatitis (in certain instances) v Malnourished or at risk to become malnourished o If oral intake is inadequate to restore or maintain optimal nutritional status 9 9 Potential Contraindications v Non-operative mechanical GI obstruction (distal, ie colon) v Intractable vomiting/diarrhea refractory to medical management v Severe short bowel syndrome v Persistent (postoperative) ileus v Distal high-output fistulas (>500 mL) v Severe GI bleed or malabsorption v Inability to gain access to the GI tract v Need is expected for less than 5-7 days o sometimes still indicated (eg in ICU) o case by case basis v Aggressive intervention is not warranted or desired o by the patient or proxy 10 10 5  9/17/24 Short-Term Access v Nasogastric Tube (NGT) o Requires normal GI function; uses normal digestive, hormonal and bactericidal processes in the stomach o Short-term nutrition support (3-4 weeks) o Tube placement verified by § Aspiration of gastric contents in combination with auscultation § Radiographic confirmation of tube tip location o Typically there is faster initiation of TF with NGT than with NJT v Nasoduodenal (NDT) or Nasojejunal (NJT) o Tube is passed through nose post-pylorically into small bowel o Patients who cannot tolerate gastric feeds § Gastric motility disorders § Esophageal reflux § Persistent nausea and vomiting o Tubes have weighted tips to guide placement § Endoscopic/fluoroscopic guidance for placement is usual § Radiologic verification 11 11 12 12 6  9/17/24 Complications v Potential Complications of Nasogastric Tubes (NGT) o Esophageal strictures o Gastroesophageal reflux resulting in aspiration pneumonia o Tracheoesophageal fistula o Incorrect position of the tube leading to pulmonary injury o Mucosal damage at the insertion site o Nasal irritation and erosion o Pharyngeal or vocal cord paralysis o Rhinorrhea, sinusitis, otitis media o Ruptured gastroesophageal varices in hepatic disease o Ulcerations or perforations of upper GI tract and airway 13 13 Long Term Access v Percutaneous endoscopic gastrostomy (PEG) or Percutaneous endoscopic jejunostomy (PEJ) placement o Nonsurgical techniques for placing feeding tube directly into stomach through the abdominal wall, using endoscope and local anesthesia § Tubes guided from nose to stomach or jejunum and brought out through abdominal wall for access § Short procedure time and limited anesthesia requirements § Very common method of feeding tube placement § Refers to the method of placement (procedure) not the tube itself § Tube placed by PEG can be converted to gastrojejunostomy Threading a small tube through the larger tube into jejunum v Surgical gastrostomy (G-tube) or jejunostomy (J-tube) placement o Feeding tube placed surgically while patient is sedated 14 14 7  9/17/24 Percutaneous endoscopic gastrostomy (PEG) 15 15 Surgical gastrostomy (G-tube) or jejunostomy (J-tube) placement 16 8  9/17/24 Multiple Purpose Gastrostomy v Gastric suction (decompression) v Jejunal feeding 17 17 18 18 9  9/17/24 Enteral Access Sites 19 19 20 20 10  9/17/24 Types and Categories of Enteral Formulas v Formulas often classified based on protein or overall macronutrient composition vThree basic categories o Polymeric (intact) o Monomeric (hydrolyzed, pre-digested) o Disease-specific 21 21 Standard Intact v Polymeric formulas o Contain intact macronutrients o Intended for normal or near normal GI function o Typically provide 1-2 kcal/mL § 1.5-2kcal/mL concentrated formulas, useful when fluid restriction required o 300-500 mOsm/kg (Isotonic) o Lactose free o Least costly v Polymeric formula examples o Osmolite (Abbott) o Jevity (Abbott) o Nutren (Nestle) 22 22 11  9/17/24 Hydrolyzed v Indicated for patients with gastrointestinal compromise requiring hydrolyzed nutrients for improved digestion v Chemically defined, peptide-based, monomeric, elemental or semi-elemental o Typically 1-1.2 kcal/mL o Lactose free o Low fat, MCT based o More expensive v Formula examples o Peptamen (Nestle) o Vivonex (Nestle) o Vital (Abbott) 23 23 Formula Content v Carbohydrates o CHO content varies from 30-85% of kcals o Sources: monosaccharides, oligosaccharides, dextrins, hydrolyzed corn starch, maltodextrins; corn syrup typically used in standard formulas § Sucrose added to flavored formulas meant for oral consumption § Hydrolyzed formulas contain cornstarch or maltodextrin § All commercially available enteral formulas are lactose free o With or without added dietary fiber (both soluble and insoluble) § Fiber added formulas thought to improve stool consistency § Evidence for benefits of fiber added formulas is mixed § Improved bowel function more often attributed to soluble fiber, but many enteral formulas contain lower amount of soluble fiber (hydrophilic) Attracts water, causes enteral formula to thicken and form a gel o Fructooligosaccharides (prebiotics) may also be added (beneficial bacteria production) § Use may contribute to undesirable GI symptoms (gas, bloating, diarrhea) 24 24 12  9/17/24 Formula Content v Lipid o Sources: corn, soy, safflower, canola, fish oils o Majority in form of LCTs and MCTs, some structured lipids (LCT + MCT) § Structured lipids absorbed more readily, better tolerated § Most of the LCTs in structured lipids are omega-3 fatty acids § Elemental formulas typically in MCT form; MCTs do not require bile salts or pancreatic lipase for digestion, absorbed directly into portal circulation v Protein o Typically derived from whey, casein, or soy protein isolate o Standard formulas contain intact protein that requires enzymes to split the nutrient into peptides before absorption o Elemental formulas contain di- and tri-peptides and amino acids (hydrolyzed) § Used for enzyme deficiency, malabsorption, et al 25 25 Vitamins, Minerals, Electrolytes v Most formulas meet RDI for vitamins/minerals in average volumes provided to patients (~1500ml in 24hours on avg) o Electrolytes provided but if patient has excessive losses (ie diarrhea or drainage loss) may need to supplement o If inadequate volume of tube feed, may need liquid MVI v Renal and hepatic formulas o Intentionally low v Immune enhancing o Supplemented with antioxidants 26 26 13  9/17/24 Fluid & Free Water Flushes v Fluid sources o Oral o Enteral o IV v Water in tube feed formulas o Standard formulas contain ~85% water by volume o Concentrated formulas contain ~70% water by volume v Water used to flush tube before/after feedings or medications v Additional free water flushes needed to meet fluid requirements o Example: 250ml q6 hours (every 6 hours) = 1000ml per day o Example: 150ml q4 hours (every 4 hours) = 900ml per day 27 27 Formula Composition v Energy v Fluid o 1 to 1.2 kcal/mL = standard o Standard ~85% water by volume o 1.5 kcal/mL o Concentrated ~70% water by volume § concentrated § helpful to reduce volume o 2 kcal/mL v Vitamins & Minerals § highest concentration o Most (but not all) formulas provide § less free water the dietary reference intakes (DRIs) within a specified volume v Protein § Usually 1500ml in 24-hours o From 4% to 26% of kcal o Typically 14% to 16% of kcal o 18% to 26% of kcal considered to be high-protein 28 28 14  9/17/24 Modulars v Provide protein, fat or carbohydrate as single nutrients to alter the nutrient composition of commercial formulas or food o Examples: § ProSource (protein, liquid) § Beneprotein (protein) § Benefiber (fiber) § Benecalorie (protein/fat) § Polycose (carbohydrate) o Increased costs o Increased labor, for mixing o Potential for clumping, clogging of tubes 29 29 Diabetic Formulas v Diabetic formulas are lower in total carbohydrates and vary in type of carbohydrates v Added fiber: soluble and insoluble v Difficult to show clinical benefit with use of these formulas compared to standard formulas o may be appropriate to trial with difficult to control BG o bolus vs continuous feeds v Examples: Glucerna (Abbott), DiabetiSource AC (Nestle) 30 30 15  9/17/24 Renal Formulas v Formulas designed for patients with renal disease o Adjusted protein, electrolyte, fluid, vitamin & mineral content compared to standard formulas Contain lower levels of potassium and phosphorus Concentrated (1.8kcal/kg) Examples: Nepro, Suplena (less protein) v End stage renal disease (ESRD) on dialysis o To meet higher protein needs, additional protein supplementation may be necessary (beneprotein) o In absence of elevated potassium or phosphorus labs, preferable to continue standard high-protein formula 31 31 Hepatic Formulas v Calorically dense; total protein is usually very low o Increased levels of BCAA (branched chain amino acids) § valine, leucine, isoleucine o Decreased levels of AAA (aromatic amino acids) § phenylalanine, tyrosine, tryptophan o Examples: NutriHep, Hepatic Aid II v Results of studies using these formulas are inconclusive in comparison to standard polymeric formulas o Typically not used in practice o Routine use of BCAA enriched enteral formulas with advanced liver disease/hepatic encephalopathy not recommended § Liver patients have increased risk +incidence of malnutrition o Use of standard formulas recommended unless refractory HE and patient unable to tolerate standard formula without precipitation of hepatic encephalopathy 32 32 16  9/17/24 Pulmonary Formulas v Higher in fat o Soy/safflower/corn oil based formulas v Lower in CHO to produce less carbon dioxide v Use of these formulas is controversial o Trials demonstrating clear benefit from these formulas are lacking § Total caloric intake has more impact on respiratory function than macronutrient content o Typically not available or used in most facilities v Examples: NovaSource Pulmonary, NutriVent o Oxepa: Specialized (high fat) formula for acute respiratory distress syndrome (ARDS) 33 33 Immune Enhancing v Contain immune-enhancing nutrients o Arginine o Glutamine o Omega-3 fatty acids o Nucleotides v Enhanced amounts of antioxidants v Routine use not recommended o May be indicated more in surgery and trauma o Not recommended for use with septic or critically ill patients v Examples: Impact Advanced Recovery, Ensure Surgery 34 34 17  9/17/24 Blenderized (Homemade) v Made from real ingredients o Liquefied in blender v Potential Advantages: o Cost effectiveness (commercial formulas may not be covered by insurance) o Uses whole foods (phytochemicals et al) o Ability to tailor formula to patient’s specific needs (ie food allergies, etc) o Social aspects: bond between patient and caregiver, caregiver takes part in preparation of the meal, sharing family meals, varied diet, sight and aroma of foods v Potential Disadvantages: o Increased risk for microbial contamination (contraindicated for immunocompromised) o Cannot be used with continuous feeding (unless formula hangs for 100% RDI o Patient receives 50 mL Osmolite 1.5 x 12 hours/day § 600 mL TV § Receiving