Adult Enteral Nutrition Deciphering the Code Mark H

Adult Enteral Nutrition Deciphering the Code Mark H. De. Legge, MD, FACG, AGAF, FASGE Digestive Disease Center Charleston, SC

Indications for EN • “If the gut works…use it” • EN is the preferred route of nutrition when oral intake is inadequate or a patient is unable to eat.

What Do We Infuse?

Formula Selection • Assess digestive and absorptive capacity and GI tolerance • Determine kcal, protein, fluid, vitamin and mineral requirements • Determine if there any mineral or electrolyte restrictions • Assess indication for specialty formula • Identify tube of type and infusion method

What’s the Situation • • 65 y/o F s/p CVA NG tube for feeding Weight: 60 kg Est kcal needs: 1500 kcal/day (25 kcal/kg/day) Est protein needs: 60 gram/d (1 gm/kg) Normal gastrointestinal function No mineral or electrolyte restrictions – Renal disease

Tube Feeding Formulas • • *Blenderized (Table food) Standard isotonic (Most common) HN - High nitrogen Nutrient dense Fiber-containing Hydrolyzed Specialty

Formula Cal/cc Standard 1. 06 Protein/L Free H 20/L (gm) 44 842 Calorie Dense High Nitrogen Small Peptide 2. 0 84 700 1. 3 67 837 1. 0 40 - 75 850 Immune Enhancing 1. 5 94 759 Hydrolyzed 1. 0 42 867

In Our Patient • Normal GI function • No need for high protein diet • No evidence of renal failure, uncontrolled diabetes • No requirement of “high-tech” specialty formula • 1500 kcal/24 hours = 60 cc/hr

Blenderized Product • • • § Essentially blenderized table food 1 calorie/cc 85. 4% water Osmolality: 340 mosmo Lactose-free Moderately expensive Compleat-B

Standard Enteral Products § § § Low residue 1 cal/cc 300 m. Osmo Lactose-free Inexpensive, moderately palatable Casein protein - biological value lower than other sources of protein

Nutrient Dense Formulas § § § § Low residue Functional GI tract required Lactose-free Inexpensive, moderately palatable Casein protein Fluid restricted patients Renal compromised patients Nutren 2. 0, Magnacal, Jevity 1. 5

High Nitrogen Products § § § Low residue Functional GI tract required Lactose-free Inexpensive, moderately palatable Casein protein, higher concentration Patients with wound healing, post-surgical, trauma, sepsis § Example: Replete, Osmolite HN

Peptide-Based Formulas § Protein source: short peptides +/- free AAs § In times of stress small bowel mucosa ability to absorb short peptides increases § Altered GI tract absorption § Critical care § Inflammatory bowel disease § More expensive than standards § Example; Peptamen, Perative

Dipeptides, Tripeptides, Short Peptides • Small intestine absorption (Pep. T 1) • Fasting: increase in small intestine (Pep. T 1) and (Pep. T 1 MRNA) at the small bowel mucosa (peptides 6 -100 in length) • Inflammatory gut conditions – increase in small intestine (Pep. T 1) production • Ogihara et al; Histochem J, 1999

Elemental Formulas § § § Macronutrients in most elemental form Protein: Free AAs Fat: MCT, long-chain fats CHO: glucose polymers Expensive, unpalatable, High osmolality Example: Crucial, Vital HN, Vivonex

Our Patient • 1500 kcal, 60 gm protein, 1800 cc H 20 • Standard: – 1. 5 liters (1500 kcal) – 66 gm protein – 1270 cc/H 20 • Nutrient dense (2 cal/ cc) – 750 cc – 63 gm protein – 462 cc H 20

Specialty Additives

Immune Enhancing Formula

Immune Modulating Ingredients • • • Definition L-Arginine Glutamine Dietary Nucleotides N-3 Fatty Acids

Immune Modulating Nutrition: Meta-Analysis Author Journal # of Pts Studies Outcome Heys Ann Surg 1999 1009 11 Dec infection Beale CCM 1999 1482 12 Dec infection Dec vent Heyland JAMA 2001 2419 22 Dec infection Dec LOS Waitzberg WJS 2006 (in press) 17 Dec infection Dec LOS 2305

Consensus Recommendations Appropriate Patient Populations • Patients undergoing elective GI surgery: benefit in malnourished Greatest • Trauma patients with ISS 18 or ATI 20 • Needs further study • Patients with severe sepsis • Other patients that may benefit: – Ventilator dependent – Elective surgery (prolonged need for ventilator, cancer with malnutrition) – Severe head injury – Burns 30% (third degree) – Head and neck cancer

Metabolic Effects of Lipids • Omega-3 series – – – Vasodilatory Anti-inflammatory Anti-aggregatory Immunostimulant Anti-arrhythmic • Omega-6 series – – – Vasoconstrictive Pro-inflammatory Pro-aggregatory Immunosuppressive Pro-arrhythmic

Enteral Formulations Medium Chain Triglycerides • Easier absorption • Less pancreatic stimulation • Less immune suppressing

Medium Chain Triglycerides • 24 HIV + patients with malabsorptive disease • LCT vs MCT enriched oral formulas • 3 day 100 gm fat diet, then trial diet 3 days Gm/Day • Craig et al; JADA, 1997 LCT

Types of Feeding Administration • Continuous- given over 24 hours • Bolus - syringe feedings given every few hours (e. g. 240 cc every 4 hours) • Nocturnal - TF given over 8 -12 hours at night while patient is sleeping

Conclusion Know the code • Assess GI tolerance • Determine calorie, water, protein needs • Evaluate co-morbidities • Determine any special needs • Determine infusion method • Write the nutrition prescription