ENTERAL NUTRITION MEETING NUTRIENT NEEDS Selection of Feeding

ENTERAL NUTRITION MEETING NUTRIENT NEEDS

Selection of Feeding Route ¨ Page 536, Krause – Figure 23 -1 ¨ Algorithm or Decision Tree – Adequate oral intake – Oral intake + supplements – Enteral nutrition support • • Patient’s medical status Anticipated duration of tube feeding Risk for aspiration Advantages and disadvantages of access route

Enteral Formula Selection ¨ Selection Algorithm: Page 538, Krause – Figure 23 -3 ¨ Feed as close to the farm as possible: e. g. the most intact formula the patient will tolerate ¨ Intact nutrient, general purpose formulas are the least expensive and may be more physiological

Enteral Formulary – What products are available? – More cost effective to have formulary – Include multiple products, one main brand of each category

Where can you get information about enteral products? ¨ Nutrition Care Manual formulary page ¨ http: //nutritioncaremanual. org/universi 13 ¨ Novartis Nutrition USA http: //www. novartisnutrition. com/us/home ¨ Abbot Nutrition Product Handbook http: //abbottnutrition. com/product. Handbook/ default. asp Nestle Nutrition http: //www. nestleclinicalnutrition. com/

Nutrition Care Manual Formulary You can ¨ View compositional information about adult and pediatric formulas ¨ Calculate nutrient delivery based on volume ¨ Compare two formulas in the same category ¨ BUT: be aware that the most reliable and up to date source of information about a formula is from the mfr.

Enteral Selection ¨ Blenderized – Compleat or homemade (CAUTION!) ¨ Standard Isotonic – Osmolite, Nutren, Isosource ¨ Added fiber – Jevity, Impact with Fiber, Nutren with Fiber, – Nutren Replete with Fiber, Nutren 1. 5 Fiber, Fibersource HN,

Enteral Selection ¨ Extra calories/volume restricted – Osmolite 1. 2, Two. Cal HN, Novasource 2. 0, Nutren 1. 5, Nutren 2. 0, Peptamen 1. 5, Jevity 1. 2, Jevity 1. 5 ¨ High nitrogen – Osmolite HN, Two. Cal HN, Fibersource HN, Peptamen VHP, Isosource HN

Enteral Selection ¨ Disease specific – Diabetes: Resource Diabetic, Diabetisource, Glucerna Select – Pulmonary: Nutren Pulmonary, Pulmocare, Novasource Pulmonary, Oxepa – Renal: Novasource Renal, Nepro, Suplena, Nutren Renal – Nutri. Hep (liver disease) – Prosure (cancer)

Enteral Formula Selection ¨ Trauma/Critical Care: Traumacal, Perative, Impact, Alitraq, Oxepa, Promote, Pivot ¨ Wound Healing: Isosource VHN, Replete, Promote, Juven (oral)

Enteral Selection ¨ Peptide based – Peptamen, Vital, Crucial, Optimental, Vital HN, Perative, Peptinex DT, Alitraq ¨ Free Amino Acids – Vivonex varieties, f. a. a. ¨ Modulars – Beneprotein Instant protein powder – Benefiber – Polycose, Benecalorie, Moducal – MCT oil, Microlipid

Pediatric (ages 1 -10) ¨ Standard: Resource Just For Kids, Pediasure, Compleat Pediatric, Nutren Jr ¨ Fiber: Resource Just for Kids w/ Fiber, Pediasure with Fiber, Nutren Jr/Fiber ¨ Elemental: Vivonex Pediatric, Petamen Jr, Pediatric Peptinex DT ¨ Infants: Appropriate infant formulas are used for infants

Enteral Selection ¨ Substrates – CHO, protein, fat: consider pt’s ability to digest, absorb nutrients ¨ Elemental vs intact formulas – Use products with MCTs if unsure of ability to digest fats – Peptides may be used as well as aa’s for most ¨ Tolerance factors – Osmolality, calorie and nutrient densities, residue content, etc.

Physical Properties of Enteral Formulas ¨ Osmolality – Vomiting – GI emptying – Diarrhea – Retention – Nausea – Dehydration ¨ Residue ¨ Viscosity – Size of tube is important

Osmolarity vs Osmolality ¨ Osmolarity – Measure of osmotically active particles per liter of solution ¨ Osmolality * – Measure of osmotically active particles per kg of solvent in which particles are dispersed – milliosmoles of solute per kg of solvent (m. Osm/kg)

Osmolality ¨ Isotonic formula = osmolality ~300 m. Osm ¨ Body attempts to restore the 280 – 300 m. Osm ¨ Enteral feedings range from < 300 – 700 m. Osm/kg ¨ Formulas with high osmolality may cause shift of water into intestinal space = rapid transit, diarrhea ¨ Medications tend to be hypertonic, particularly elixirs; may need to be diluted to decrease hypertonicity when given via tube

Lower Osmolality ¨ Large (intact) proteins ¨ Large starch molecules

Higher Osmolality ¨ Hydrolyzed protein or amino acids ¨ Disaccharides ¨ Smaller particles

Osmolality of Selected Liquids/ Medications Liquid or Drug m. Osm/kg EN formulas 250 to 710 Milk 275 Sodas Juices 695 ~990 Ice Cream 1150 Acetominophen elixir 5400 Diphenoxylate suspension 8800 Chloral hydrate 4400 Metoclopromide 8350

Meeting Nutrient Needs ¨ Calculate kcal, protein, fluid, and nutrient needs according to age, sex, medical status ¨ Select appropriate formula based on nutritional needs, feeding route, and GI function

Estimation of Energy Needs • Indirect calorimetry: the gold standard, particularly with critically ill, obese, pts who do not respond well to treatment • Most clinicians use standard energy estimation equations to estimate calorie needs

In-Class Use of Predictive Equations for EEE and REE ¨ Use actual body weight in calculations in class ¨ Use Mifflin-St. Jeor plus activity factors, if applicable, in ambulatory patients ¨ Use Harris-Benedict x injury factor with actual weight in hospitalized, stressed patients. Do not use activity factor unless patients are in rehab or unusually active. ¨ ADA Nutrition Care Manual, www. nutritioncaremanual. org, accessed 1 -06

In-Class Use of Predictive Equations for EEE and REE ¨ Use 1992 Ireton-Jones in patients with burns and trauma where Penn State data not available ¨ Use Penn State equation in the ICU where minute ventilation and temperature available

In-Class Use of Predictive Equations for EEE/REE ¨ In calculating protein needs, use actual weight, but use the lower end of ranges for persons with Class I obesity or above. ¨ It’s always best to estimate a range of needs, which reflects the imprecision of the tools available for our use.

Quick Method ¨ Use 25 -35 kcal/kg in hospitalized non-obese patients ¨ FAO-WHO. Energy and protein requirements. Geneva: WHO, 1985. Technical report series 724. ¨ Use 20 -21 kcal/kg actual body weight in obese patients (BMI>30) ¨ Amato P, Keating KP, Querica RA, et al. Formulaic methods of estimating caloric requirements in mechanically ventilated obese patients: a reappraisal. Nutr Clin Pract 1995; 10: 229 -230.

Meeting Nutrient Needs ¨ Enteral Formulas – caloric density: – 1. 0 -1. 2 kcal/ml – 1. 5 kcal/ml – 2. 0 kcal/ml – Energy and nutrient concentration affect volume needed • 1 kcal/m. L = standard formula • 1. 5 -2 kcal/m. L = volume limitations

Protein ¨ 0. 8 – 1. 0 g/kg for maintenance ¨ 1. 25 for mild stress ¨ 1. 5 for moderate stress ¨ 1. 75 – 2. 0 for severe stress, trauma, burns – Escott-Stump. Nutrition and Diagnosis-Related Care. 5 th edition. P. 694 ¨ Or use University of Akron Assessment standards

Protein (continued) ¨ Protein (N = gm pro ÷ 6. 25) – Based on Kcal intake (NPC: N) – Normal = 200 -300: 1 – Anabolism = 150: 1 – Protein malnutrition = 100: 1 – Critical illness = 150 -200: 1 – Energy malnutrition = >200: 1

Vitamins and Minerals ¨ Vitamins and minerals – Determine if DRIs for v/m can be met with calculated volume – Remember that DRIs are set for healthy people – May need to add v/m supplement • liquid drops thru tube • crushed pill (CAUTION!)

Fluid Needs Based Upon Method Weight 100 ml/kg BW 1 st 10 kg 50 ml/kg BW next 10 kg 20 ml/kg BW/kg above 20 kg Holiday-Seger Method Weight and age 16 -30 years, active: 40 ml/ kg BW 20 -55 years: 35 ml/kg BW 55 -75 years: 30 ml/kg BW Energy needs 1 ml/kcal estimated energy needs or 30 -35 ml/kg body weight Food and Nutrition Board, NAS, Recommended Dietary Allowances 10 th Editiion, 1989; Charney and Malone, ADA Pocket Guide to Nutrition Assessment, 2004, p. 166

Meeting Fluid Needs in Enterally-Fed Patients ¨ Water in Enteral Products – Calculate free water: • 1 kcal/ml = ~85% free water (850 m. L per 1, 000 m. L formula) • 1. 2 -1. 5 kcal/m. L = 69% - 82% (690 -820) • 1. 5 -2. 0 kcal/m. L = 69% - 72% (690 -720) • Exact water content on label or in manufact’s info – Subtract amt. free water from needs – Provide additional water via flushes

Meeting Fluid Needs in Enterally Fed Patients ¨ Water Flushes – Irrigate tube q 4 hrs with 20 -60 m. L water with continuous feeds – Irrigate tubes before and after each intermittent or bolus feed with 20 -60 m. L water – In case of clogging, tube should be flushed using 60 m. L syringe with 30 -60 m. L warm water – Use smaller vol for fluid-restricted pts

Meeting Fluid Needs in Enterally -Fed Patients ¨ Water – Increase fluids as tolerated to compensate for losses: • • • fever or environmental temp increased urine output diarrhea/vomiting draining wounds ostomy output, fistulas increased fiber intake, concentrated or highprotein formulas

Enteral Nutrition Monitoring ¨ Wt (at least 3 times/week) ¨ Signs/symptoms of edema (daily) ¨ Signs/symptoms of dehydration (daily) ¨ Fluid I/O (daily) ¨ Adequacy of intake (at least 2 x weekly) ¨ Nitrogen balance: becoming less common (weekly, if appropriate)

Enteral Nutrition Monitoring ¨ Serum electrolytes, BUN, creatinine (2 – 3 x weekly) ¨ Serum glucose, calcium, magnesium, phosphorus (weekly or as ordered) ¨ Stool output and consistency (daily)

Enteral Feeding Tolerance ¨ Signs and symptoms: —Consciousness —Respiratory distress —Nausea, vomiting, diarrhea —Constipation, cramps —Aspiration —Abdominal distention

Monitoring Gastric Residuals ¨ Performed by inserting a syringe into the feeding tube and withdrawing gastric contents and measuring volume ¨ Often a part of nursing protocols/physician orders for tubefed patients

Enteral Nutrition Monitoring: Gastric Residuals ¨ The value and method of monitoring of gastric residuals is controversial ¨ Associated with increase in clogging of feeding tubes ¨ Collapses modern soft NG tubes ¨ Residual volume not well correlated with physical examination and radiographic findings ¨ There are no studies associating high residual volume with increased risk of aspiration

Absorption/Secretion of Fluid in the GI Tract Addtions (m. L) Diet Saliva Stomach Pancreas/Bile Intestine Subtractions (m. L) Colointestinal Net stool loss 2000 1500 2000 1000 8900 100 Harig JM. Pathophysiology of small bowel diarrhea. Cited in Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18; 75 -85.

Enteral Nutrition Monitoring: Gastric Residuals ¨ Monitoring of gastric residuals in tubefed pts assumes that high residuals occur only in tubefed pts ¨ In one study, 40% of normal volunteers had RVs that would be considered significant based on current standards ¨ For consistency, all hospitalized pts, with or without EN should have their RVs routinely assessed to evaluate GI function Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18; 75 -85.

Enteral Nutrition Monitoring: Gastric Residuals ¨ Clinically assess the patient for abdominal distension, fullness, bloating, discomfort ¨ Place the pt on his/her right side for 15 -20 minutes before checking a RV to avoid cascade effect ¨ Try a prokinetic agent or antiemetic ¨ Seek transpyloric access of feeding tube ¨ Raise threshold for RV to 200 -300 m. L ¨ Consider stopping RV checks in stable pts Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr Clin Pract 2003; 18; 75 -85.