Enteral Nutrition Support Intern Class Day December 7

Enteral Nutrition Support Intern Class Day December 7 th, 2015 Christina Di. Segna, MS, RD, LDN, CNSC Senior Inpatient Clinical Dietitian Brigham and Women’s Hospital

Outline • Brief History of Enteral Nutrition • Indications/ Contraindications • When to feed • Type of access • Formula selection • Feeding regimen • Monitoring tolerance • Complications • Case studies

History of Enteral Nutrition • Used as early as the 18 th century • Individuals who were unable or unwilling to consume adequate amounts of food were fed via wooden or glass tubes • Dangerous and only used as a last resort • Formulas were primitive • Broth, milk, eggs

History of Enteral Nutrition • With the advent of modern medicine we began to see advances in technology and formulas for EN • However EN technology has developed slowly • Development of parenteral nutrition in the 1960’s led to underutilization of EN for some time

Enteral vs Parenteral Nutrition • “If the gut works, use it. ” • Enteral nutrition has been proven safer and more cost effective than parenteral nutrition in many settings • Fewer complications associated with enteral nutrition when compared to parenteral nutrition • Enteral nutrition preserves intestinal function

Indications for Enteral Nutrition • Failure to meet energy needs with voluntary oral intake ◦ ◦ ◦ ◦ Impaired ability to ingest food Alterations in nutrient requirements Alterations in digestion and absorption Comatose state Mechanical ventilation GI failure- i. e. SBS Chronic illness, significant weight loss, and signs of macro & micro nutrient deficiencies

Absolute Contraindications to EN • Diffuse peritonitis • Gastrointestinal ischemia • Intestinal perforation • Distal small bowel or large bowel obstruction • Unable to obtain enteral access • Hemodynamic instability

Potential Contraindications to EN • Malnourished patient expected to eat within 5 -7 days • High output proximal fistula • Intractable nausea and vomiting • Malabsorption • Ileus • Aggressive therapy/nutrition support is not warranted • Some patients may require simultaneous EN and TPN support

When to Feed • Evaluated bowel function • Bowel sounds—absence does not preclude safe start of enteral nutrition • Paralytic ileus • Absence of flatus or bowel movements • Ileus affects different areas of the intestine • NGT in place for decompression • Consider starting enteral nutrition • Presence of soft, non tender abdomen • Good perfusion of extremities • Hemodynamic stability

Question 1 • Which patient would be an appropriate candidate for enteral nutrition support? • A. Severe neurological impairment • B. Post uncomplicated colonic resection • C. Short bowel syndrome • D. A and C

Gastric vs Small Bowel Feeding • Advantages to gastric feeds • Tubes are easier to place and replace • Large bore tubes help prevent occlusions • Infusion pumps may not be necessary over the long term

Small Bowel Feeding • Small bowel feeding may be an alternative if small intestine and colon functioning • Consider small bowel feeds • Gastroparesis, gastric ileus • Significant gastroesophageal reflux • Recent stomach surgery • Pancreatitis • High risk for aspiration • Gastric outlet obstruction

Short Term Access • Nasogastric tube (NGT) • Considerations • • Need functioning stomach Can use large or small bore tubes Smaller tubes clog more easily Radiographic confirmation of placement • Benefits • Easily inserted and replaced • Large bore tubes can accommodate medications, benefiber, protein supplements • Large bore tubes are better for checking residuals

Short Term Access • Nasoenteric tube • Considerations • Use in patients with aspiration risk, poor gastric emptying, or gastroparesis • Cannot check gastric residuals • Requires continuous or cycled infusion • Benefits • Some tubes allow decompression of the stomach while feeding into the small bowel

Long Term Access • Gastrostomy (G-tube) • Open surgical procedure or PEG • Considerations • Not optimal choice for patients with ascites, gastric emptying issues, or history of reflux • Benefits • Allows for bolus feeding which is physiologically normal • Can be converted to jejunal feeding if necessary

Long Term Access • Jejunostomy (J-tube): Surgically or endoscopically placed • Considerations • Requires continuous/cycle infusion • Use in patients at risk for aspiration, gastroparesis, or s/p esophagectomy • Cannot check gastric residuals • Benefits • May reduce aspiration risk of TF formula • Can be used for patients with intermittent nausea/vomiting

Long Term Access • Transgastric jejunostomy ◦ Considerations • Requies continuous infusion • Can use in patients with poor gastric emptying, gastroparesis, post-op ileus • Cannot check residuals ◦ Benefits • May reduce aspiration of TF formula • Allow decompression of the stomach while feeding small bowel • Can be converted to gastric tube later

Question 2 • 45 yo male with history of poorly controlled diabetes, admits with nausea and vomiting x several months, complains of early satiety and significant weight loss. Symptoms are not resolved with promotility agents. Should a feeding tube be placed? If so, what type and why?

Choosing an Appropriate Formula • Categories of Enteral Formula • Monomeric: predigested nutrients; must have low fat content or high % of MCT’s; for use in patients with impaired GI function • Polymeric: intact proteins, use for patients with normal or near normal GI function • Disease specific: for use in specific disease states

Monomeric Formula Examples • Vivonex (Nestle) • Elemental nutrition (“pre-digested”) • Low fat • Hyperosmolar • Perative (Abbott) or Peptamen (Nestle) • Semi-elemental • May be indicated with malabsorptive disorders

Polymeric Formula Examples • Two Cal HN (Abbott) or Nutren 2. 0 (Nestle) • Most concentrated at 2 cal/m. L, hyperosmolar • Osmolite (Abbott) or Nutren (Nestle) • Standard formula • 1 cal/m. L (isotonic); 1. 2 cal/m. L; 1. 5 cal/m. L • Jevity (Abbott) or Nutren 1. 0 Fiber (Nestle) • Standard formula with fiber • 1 cal/m. L (isotonic); 1. 2 cal/m. L; 1. 5 cal/m. L • Jevity contains soluble and insoluble fiber

Disease Specific Formulas • Glucerna (Abbott) or Diabetisource (Nestle) • For diabetes • Fiber containing, low carb • Nepro (Abbott) or Novasource Renal (Nestle) • For renal disease • Electrolyte and fluid restricted, 1. 8 cal/m. L • High in protein, low carb • Nutri-Hep (Abbott): • Liver failure with fulminate encephalopathy • BCAA, Low in protein

Choosing an Enteral Formula • Hemodynamic stability • Is the patient in the ICU? • Choose fiber free • Previous diet tolerance • Regular diet: trial polymeric formula • Malabsorption: fiber free vs semi-elemental • Special nutrient needs • Low glycemic index • Indication for immune modulators • L-Arginine • Omega-3’s

Choosing an Enteral Formula • Electrolyte balance • Does the pt need potassium and phosphorous restriction? • Fluid needs • • • Euvolemic? Volume overload? Hypo or hypernatremia? Elderly? Diarrhea/constipation?

Types of Feeding Administration • Continuous feeding • Controlled amount of formula delivered each hour by pump • Intermittent feeding • Delivered by gravity using a bag or syringe (bolus) • For adult patients, usually 250 -500 m. L can be delivered each feeding

Determining TF Goal • Calculate energy and protein needs • Determine strength of formula • Example: 1. 2 kcal/m. L • Determine volume of TF required to meet needs • Divide energy requirements by strength • Decide on how TF will be infused and divide by frequency • Example: bolus (TID) vs continuous (24 h) vs cycle (16 h) • Calculate protein provided by TFs and use modular if indicated

Fluid Needs • Estimate your patient’s fluid needs • 30 -35 m. L/kg • 1 m. L per kcal • 1000 m. L x body surface area • Calculate free water from TFs • 1 kcal/m. L: 84% water • 1. 2 kcal/m. L: 82% water • 1. 5 kcal/m. L: 76% water • Volume of TFs x % water/100 • Final calculation: Pt requirement – water from TF= amount to give as free water/IVF/flushes/bolus

Initiating & Advancing Feeding • ASPEN guidelines • Continuous feeding • In stable adult patients, can initiate full strength formula at 10 -40 m. L/hr and advance 10 -20 m. L/hr every 4 -8 hours until goal rate is achieved • Different institutions have different guidelines • Bolus feeding • Initiate with 120 m. L bolus, advance by 60 -120 m. L bolus every 8 -12 hours as tolerated. • Typical goal volume per bolus: 250 -500 m. L • Number of feedings/day depends on amount of formula needed to meet energy needs

Writing your Recommendation • Formula name • Initiation rate • Advancement rate • Goal rate • Additional fluid needs

Monitoring Enteral Feeding • Refeeding risk • Electrolytes: K, PO 4, Mg • Trend Prealbumin, CRP • Monitor blood sugars • Monitor weight • Monitor enteral infusion volume • Appropriateness for cycling/bolus • Skin integrity

GI complications • Nausea and vomiting • Increase risk of aspiration • Abdominal distention • Could indicate ileus, obstruction • Constipation • Look into hydration status, inadequate or excessive fiber

Diarrhea • No universal definition for diarrhea • Normal stool output is 250 -500 m. L/day • Investigate potential causes of diarrhea • Infectious vs osmotic • Check medication list for elixirs, sorbitols, po electrolyte repletion • Check fiber provision • Check osmolality • Troubleshoot: change one thing at a time • • Adjust infusion rate Adjust fiber content Change formula Anti-diarrhea medication

Mechanical Complications • Tube clogging • Can be prevented with routine flushing of feeding tube • Aspiration • Symptoms include dyspnea, wheezing, anxiety, agitation • Prevention is crucial. Should maintain head of bed at appropriate angle, greater than 30 degrees

Tube Feed Clog • Myth: Coca-cola will unclog a feeding tube • Fact: Cola products actually cause coagulation of proteins in the tube and can worsen the clog and in addition, deteriorate the integrity of the tube • Use warm water to flush the tube • Trial combination of enzymes and bicarb to dissolve clog

Question 3 Which of the following is the most appropriate initial action to diarrhea for a patient on TFs? A. D/C tube feeds and start TPN B. Review medications C. Change to elemental enteral formula D. Add pro-motility agent

Summary • Enteral nutrition support is preferred over parenteral nutrition support • Evaluate appropriateness of enteral feeding on a patient by patient basis • Decide on appropriate feeding route access • Choose best formula • Monitor initiation and advancement carefully

Questions?

Case Studies

Case Study 1 70 yo F with PMH including HTN & DM admitted s/p stroke. She is awake and working with PT but has failed multiple SLP (speech & language pathologist) evaluations for an oral diet. SLP recommends NPO

Nutrition Care Plan • What is your nutrition diagnosis? • What is your plan? What route will you use to feed her?

• SLP suspects long term impairment of swallow function. Which type of access would you suggest?

Her needs are estimated to be 1700 kcal/day • Which formula and feeding regimen would you suggest?

She is unable to tolerate TF. She c/o bloating after feeds and has had multiple episodes of N/V associated with feedings. • What is your Nutrition Diagnosis?

What can you do to improve tolerance?

She continues to have N/V and residuals persistently > 400 m. L. She has a gastric emptying study which confirms severe gastroparesis. • Why do you think she has gastroparesis? • What are you going to do?

Plan is to convert to PEG-J. What is your TF recommendation? (1700 kcal, 75 g protein) What do you need to monitor when cycling? What else will you monitor for tolerance?

• She would like to do bolus feeds. What is your recommendation? Why?

Case 2 28 yo F with no significant PMH who admits with abdominal pain and findings consistent with gallstone pancreatitis. • Nutritionally, pt presents with 14 days of hypocaloric intake related to abdominal pain • What is your nutrition diagnosis?

The team makes her NPO, but recognizes that she is malnourished. They consult nutrition to assess the best route for feeding. • What do you recommend? • Why?

The team places a NJT. What do you recommend for an enteral formula? You choose a formula with 1 kcal/m. L concentration & 50 g protein/L. What is the hourly TF infusion rate needed to meet her daily goals: 2100 kcal/day and 114 g protein/day? Does she need a protein modular (6 g protein per scoop)?

Case 3 78 yo M with DM, HTN, CAD and ESRD on dialysis presents with failure to thrive. On examination by SLP, pt is considered at risk for aspiration and is made NPO. • The plan is to place an NGT until swallowing function improves.

Which tube feed formula are you going to choose? Calorie goal is 1900 kcal/day. What is the TF goal rate (concentration is 1. 8 kcal/m. L)? What are you going to monitor?

Within 24 hours of initiating enteral nutrition, his K dropped to 2. 7 m. Eq/L (3. 4 -5 m. Eq/L) and his PO 4 dropped to 1. 2 mg/d. L (2. 4 -4. 3 mg/d. L). • What are your choices?

Case 4 Your patient is getting Osmolite 1. 2 at 70 m. L/hr, continuous (goal). When you review his labs 3 days after initiation of TFs you find that his serum Na has increased to 150 m. Eq/L (normal is 136 -145 m. Eq/L). What should you do?

Solution: • Choice A • • Estimate Calorie needs: Estimate fluid needs: TF provide: Difference is: • Choice B • Increase free water provided in TF • Change to:

Questions?