Enteral and Parenteral Nutrition Support Chapter 23.

Enteral and Parenteral Nutrition Support

Enteral and Parenteral Nutrition Support

Chapter 23Chapter 23

© 2004, 2002 Elsevier Inc. All rights reserved.

Enteral Nutrition DefinitionEnteral Nutrition Definition

Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)

—Tube feedings

—Must have functioning GI tract

—IF THE GUT WORKS, USE IT!

—Exhaust all oral diet methods first.

Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)

—Tube feedings

—Must have functioning GI tract

—IF THE GUT WORKS, USE IT!

—Exhaust all oral diet methods first.


Oral SupplementsOral Supplements

Between meals

Added to foods

Added into liquids for medication pass by nursing

Enhances otherwise poor intake

May be needed by children or teens to support growth

Between meals

Added to foods

Added into liquids for medication pass by nursing

Enhances otherwise poor intake

May be needed by children or teens to support growth


Conditions That Require OtherNutrition SupportConditions That Require OtherNutrition Support

Enteral

—Impaired ingestion

—Inability to consume adequate nutrition orally

—Impaired digestion, absorption, metabolism

—Severe wasting or depressed growth Parenteral

—Gastrointestinal incompetency

—Hypermetabolic state with poor enteral tolerance or accessibility

Enteral

—Impaired ingestion

—Inability to consume adequate nutrition orally

—Impaired digestion, absorption, metabolism

—Severe wasting or depressed growth Parenteral

—Gastrointestinal incompetency

—Hypermetabolic state with poor enteral tolerance or accessibility


Conditions That Often Require Nutritional SupportConditions That Often Require Nutritional Support


Conditions That Often Require Nutritional Support –cont’dConditions That Often Require Nutritional Support –cont’d


Algorithm for Decisions Algorithm for Decisions

Modified and adapted from Gorman RC, Morris JB: Minimally invasive access to the gastrointestinal tract. In Rombeau JL, Rolandelli RH, editors: Clinical nutrition: enteral and tube feeding, p 174, Philadelphia, 1997, WB Saunders; and Ali A et al:Nutritional support services, Nutritional Support Algorithms, 8(7):13, July 1998.


Considerations in Enteral NutritionConsiderations in Enteral Nutrition

1. Applicable

2. Site placement

3. Formula selection

4. Nutritional/medical requirements

5. Rate and method of delivery

6. Tolerance

1. Applicable

2. Site placement

3. Formula selection

4. Nutritional/medical requirements

5. Rate and method of delivery

6. Tolerance


Formula SelectionFormula SelectionThe suitability of a feeding formula should be evaluated based on The suitability of a feeding formula should be evaluated based on

Functional status of GI tract

Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)

Macronutrient ratios

Digestion and absorption capability of patient

Specific metabolic needs

Contribution of the feeding to fluid and electrolyte needs or restriction

Cost effectiveness

Functional status of GI tract

Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)

Macronutrient ratios

Digestion and absorption capability of patient

Specific metabolic needs

Contribution of the feeding to fluid and electrolyte needs or restriction

Cost effectiveness


Enteral Formula CategoriesEnteral Formula Categories


Factors to Consider When Choosing an Enteral FormulaFactors to Consider When Choosing an Enteral Formula


Enteral Access: Clinical ConsiderationsEnteral Access: Clinical Considerations

Duration of tube feeding

—Nasogastric or nasoenteric tube for short term

—Gastrostomy and jejunostomy tubes for long term

Placement of tube

—Gastric

—Small bowel

Duration of tube feeding

—Nasogastric or nasoenteric tube for short term

—Gastrostomy and jejunostomy tubes for long term

Placement of tube

—Gastric

—Small bowel


Placement SitePlacement Site

Access (medical status)

Location (radiographic confirmation)

Duration

Tube measurements and durability

Adequacy of GI functioning

Access (medical status)

Location (radiographic confirmation)

Duration

Tube measurements and durability

Adequacy of GI functioning


Enteral Tube PlacementEnteral Tube Placement


Advantages—Enteral NutritionAdvantages—Enteral Nutrition

Intake easily/accurately monitored

Provides nutrition when oral is not possible or adequate

Costs less than parenteral nutrition

Supplies readily available

Reduces risks associated with disease state

Intake easily/accurately monitored

Provides nutrition when oral is not possible or adequate

Costs less than parenteral nutrition

Supplies readily available

Reduces risks associated with disease state


More Advantages—Enteral NutritionMore Advantages—Enteral Nutrition

Preserves gut integrity

Decreases likelihood of bacterial translocation

Preserves immunologic function of gut

Increased compliance with intake

Preserves gut integrity

Decreases likelihood of bacterial translocation

Preserves immunologic function of gut

Increased compliance with intake


Disadvantages—Enteral NutritionDisadvantages—Enteral Nutrition

GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax

Costs more than oral diets

Less “palatable/normal”

Labor-intensive assessment, administration, tube patency and site care, monitoring

GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax

Costs more than oral diets

Less “palatable/normal”

Labor-intensive assessment, administration, tube patency and site care, monitoring


Complications of Enteral FeedingComplications of Enteral Feeding

Access problems (tube obstruction)

Administration problems (aspiration)

Gastrointestinal complications (diarrhea)

Metabolic complications (overhydration)

Access problems (tube obstruction)

Administration problems (aspiration)

Gastrointestinal complications (diarrhea)

Metabolic complications (overhydration)


Aspiration PneumoniaAspiration Pneumonia

Can result from enteral feeds

High-risk patients

—Poor gag reflex

—Depressed mental status

Can result from enteral feeds

High-risk patients

—Poor gag reflex

—Depressed mental status


Reducing Risk of AspirationReducing Risk of Aspiration

Check gastric residuals if receiving gastric feeds

Elevate head of the bed >30 degrees during feedings

Postpyloric feeding

—Nasoenteric tube placement may require fluoroscopic visualization or endoscopic guidance

—Transgastric jejunostomy tube

Check gastric residuals if receiving gastric feeds

Elevate head of the bed >30 degrees during feedings

Postpyloric feeding

—Nasoenteric tube placement may require fluoroscopic visualization or endoscopic guidance

—Transgastric jejunostomy tube


Rate and Method of Delivery*Rate and Method of Delivery*

Bolus—300 to 400 ml rapid delivery via syringe several times daily

Intermittent─300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe

Cyclic—via pump usually at night

Continuous—via gravity drip or infusion pump

*Determined by medical status, feeding route and volume, and nutritional goals

Bolus—300 to 400 ml rapid delivery via syringe several times daily

Intermittent─300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe

Cyclic—via pump usually at night

Continuous—via gravity drip or infusion pump

*Determined by medical status, feeding route and volume, and nutritional goals


Consideration of Physical Properties of Enteral FormulasConsideration of Physical Properties of Enteral Formulas

Residue

Viscosity

—Size of tube is important

Osmolality: consider protein source

—Intact (do not affect osmolality)—soy isolates; sodium or calcium casein; lactalbumin

—Hydrolyzed (more particles)—peptides or free amino acids

Residue

Viscosity

—Size of tube is important

Osmolality: consider protein source

—Intact (do not affect osmolality)—soy isolates; sodium or calcium casein; lactalbumin

—Hydrolyzed (more particles)—peptides or free amino acids


Renal Solute LoadRenal Solute Load

Normal adult tolerance is 1200 to 1400 mOsm/L

Infants and renal patients may tolerate less

Normal adult tolerance is 1200 to 1400 mOsm/L

Infants and renal patients may tolerate less


Lower OsmolalityLower Osmolality

Large (intact) proteins

Large starch molecules

Large (intact) proteins

Large starch molecules


Higher OsmolalityHigher Osmolality

Hydrolyzed protein or amino acids

Disaccharides

Hydrolyzed protein or amino acids

Disaccharides


ToleranceTolerance

Signs and symptoms:

—Consciousness

—Respiratory distress

—Nausea, vomiting, diarrhea

—Constipation, cramps

—Aspiration

—Abdominal distention

Signs and symptoms:

—Consciousness

—Respiratory distress

—Nausea, vomiting, diarrhea

—Constipation, cramps

—Aspiration

—Abdominal distention


Tolerance—cont’dTolerance—cont’d

Other signs and symptoms

—Hydration

—Labs

—Weight change

—Esophageal reflux

—Lactose/gluten intolerances

—Glucose fluctuations

Other signs and symptoms

—Hydration

—Labs

—Weight change

—Esophageal reflux

—Lactose/gluten intolerances

—Glucose fluctuations


How to Determine Energy and ProteinHow to Determine Energy and Protein

kcal/ml x ml given = kcal

% protein x kcal = kcal as protein

kcal as protein x 1 g/4 kcal = g protein

kcal/ml x ml given = kcal

% protein x kcal = kcal as protein

kcal as protein x 1 g/4 kcal = g protein

Example: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/mlExample: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/ml

1 kcal/ml x 200 ml = 200 kcal

0.153 % protein x 200 kcal = 30.6 kcal

30.6 kcal x 1g protein/4 kcal = 7.65 g protein

1 kcal/ml x 200 ml = 200 kcal

0.153 % protein x 200 kcal = 30.6 kcal

30.6 kcal x 1g protein/4 kcal = 7.65 g protein


Energy in FormulasEnergy in Formulas

1 to 1.2 kcal/ml = usual concentration

2 kcal/ml = highest concentration

1 to 1.2 kcal/ml = usual concentration

2 kcal/ml = highest concentration


ProteinProtein

From 4% to 26% of kcal is possible

14% to 16% of kcal is usual

18% to 26% of kcal—considered to be high-protein solution

From 4% to 26% of kcal is possible

14% to 16% of kcal is usual

18% to 26% of kcal—considered to be high-protein solution


Recommended WaterRecommended Water

Healthy adult: 1 ml/kcal or 35 ml/kg

Healthy infant: 1.5 ml/kcal or 150 ml/kg

Normal tube feeding: 1 kcal/ml; 80% to 85% water

Elderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider 35 ml/kg if history of dehydration

Healthy adult: 1 ml/kcal or 35 ml/kg

Healthy infant: 1.5 ml/kcal or 150 ml/kg

Normal tube feeding: 1 kcal/ml; 80% to 85% water

Elderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider 35 ml/kg if history of dehydration


Sources of Fluid (“Free Water”)Sources of Fluid (“Free Water”)

Liquids

Water in food

Water from metabolism

With tube feeding, nurse will flush tube with water about 3 times daily—include this amount in estimated needs

—Example: “flush with 200 cc tid”

Liquids

Water in food

Water from metabolism

With tube feeding, nurse will flush tube with water about 3 times daily—include this amount in estimated needs

—Example: “flush with 200 cc tid”


Administration: Feeding Rate Administration: Feeding Rate

Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hours

Intermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hours

Bolus method = may give 300 to 400 ml several time a day (“push” is not desired)

Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hours

Intermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hours

Bolus method = may give 300 to 400 ml several time a day (“push” is not desired)


French Units—Tube SizeFrench Units—Tube Size

Diameter of feeding tube is measured in French units

1F = 33 mm diameter

Feeding tube sizes differ for formula types and administration techniques.

Diameter of feeding tube is measured in French units

1F = 33 mm diameter

Feeding tube sizes differ for formula types and administration techniques.


Examples of Special FormulasExamples of Special Formulas

Pediatrics

Low residue

High protein

Volume restriction

Diabetic

Pulmonary/COPD

Pediatrics

Low residue

High protein

Volume restriction

Diabetic

Pulmonary/COPD


Enteral Nutrition MonitoringEnteral Nutrition Monitoring


Routes of Parenteral NutritionRoutes of Parenteral Nutrition

Central access

—TPN both long- and short-term placement

Peripheral or PPN

—New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis

<2000 kcal required or <10 days

Central access

—TPN both long- and short-term placement

Peripheral or PPN

—New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis

<2000 kcal required or <10 days


PPN vs. TPNPPN vs. TPN

Kcal required(10% dextrose max. PPN conc.)

Fluid tolerance

Osmolarity

Duration

Central line contraindicated

Kcal required(10% dextrose max. PPN conc.)

Fluid tolerance

Osmolarity

Duration

Central line contraindicated


Venous Sites from Which the Superior Vena Cava May Be AccessedVenous Sites from Which the Superior Vena Cava May Be Accessed


Advantages—Parenteral NutritionAdvantages—Parenteral Nutrition

Provides nutrients when less than 2 to 3 feet of small intestine remains

Allows nutrition support when GI intolerance prevents oral or enteral support

Provides nutrients when less than 2 to 3 feet of small intestine remains

Allows nutrition support when GI intolerance prevents oral or enteral support


Indications for Total Parenteral NutritionIndications for Total Parenteral Nutrition

GI non functioning

NPO >5 days

GI fistula

Acute pancreatitis

Short bowel syndrome

Malnutrition with >10% to 15 % weight loss

Nutritional needs not met; patient refuses food

GI non functioning

NPO >5 days

GI fistula

Acute pancreatitis

Short bowel syndrome

Malnutrition with >10% to 15 % weight loss

Nutritional needs not met; patient refuses food


ContraindicationsContraindications

GI tract works

Terminally ill

Only needed briefly (<14 days)

GI tract works

Terminally ill

Only needed briefly (<14 days)


Calculating Nutrient NeedsCalculating Nutrient Needs

Avoid excess kcal (> 40 kcal/kg)

Adults

kcal/kg BW

Obese—use desired BMI range or an adjusted factor

Avoid excess kcal (> 40 kcal/kg)

Adults

kcal/kg BW

Obese—use desired BMI range or an adjusted factor


Adjusted Body WeightAdjusted Body Weight

Adjusted IBW for obesity

Female:

([actual weight – IBW] x 0.32) + IBW

Male:


Adjusted IBW for obesity

Female:


Male:



Parenteral ComponentsParenteral Components

Carbohydrate

glucose or dextrose monohydrate

3.4 kcal/g

Amino acids

3, 3.5, 5, 7, 8.5, 10% solutions

Fat

10% emulsions = 1.1 kcal/ml

20% emulsions = 2 kcal/ml

Carbohydrate

glucose or dextrose monohydrate

3.4 kcal/g

Amino acids

3, 3.5, 5, 7, 8.5, 10% solutions

Fat

10% emulsions = 1.1 kcal/ml

20% emulsions = 2 kcal/ml


Protein RequirementsProtein Requirements

1.2 to 1.5 g protein/kg IBW mild or moderate stress

2.5 g protein/kg IBW burns or severe trauma

1.2 to 1.5 g protein/kg IBW mild or moderate stress

2.5 g protein/kg IBW burns or severe trauma


Carbohydrate RequirementsCarbohydrate Requirements

Max. 0.36 g/kg BW/hr

Excess glucose causes:

Increased minute ventilation

Increased CO2 production

Increased RQ

Increased O2 consumption

Lipogenesis and liver problems

Max. 0.36 g/kg BW/hr

Excess glucose causes:

Increased minute ventilation

Increased CO2 production

Increased RQ

Increased O2 consumption

Lipogenesis and liver problems


Lipid RequirementsLipid Requirements

4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid

Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg

4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid

Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg


Other RequirementsOther Requirements

Fluid—30 to 50 ml/kg

Electrolytes

Use acetate or chloride forms

to manage acidosis or alkalosis

Vitamins

Trace elements

Fluid—30 to 50 ml/kg

Electrolytes

Use acetate or chloride forms

to manage acidosis or alkalosis

Vitamins

Trace elements


Calculating the Osmolarity of a Parenteral Nutrition SolutionCalculating the Osmolarity of a Parenteral Nutrition Solution

1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L

2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L

3. Fat is isotonic and does not contribute to osmolarity.

4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L

1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L

2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L

3. Fat is isotonic and does not contribute to osmolarity.

4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L


Compounding MethodsCompounding Methods

Total nutrient admixture of amino acids, glucose, additives

3-in-1 solution of lipid, amino acids, glucose, additives

Total nutrient admixture of amino acids, glucose, additives

3-in-1 solution of lipid, amino acids, glucose, additives


AdministrationAdministration

Start slowly(1 L 1st day; 2 L 2nd day)

Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV)

Cyclic give 12 to 18 hours per day

Start slowly(1 L 1st day; 2 L 2nd day)

Stop slowly(reduce rate by half every 1 to 2 hrsor switch to dextrose IV)

Cyclic give 12 to 18 hours per day


Monitoring and ComplicationsMonitoring and Complications

Infection

Hemodynamic stability

Catheter care

Refeeding syndrome

Infection

Hemodynamic stability

Catheter care

Refeeding syndrome


Refeeding SyndromeRefeeding Syndrome

Hypophosphatemia

Hyperglycemia

Fluid retention

Cardiac arrest

Hypophosphatemia

Hyperglycemia

Fluid retention

Cardiac arrest


MonitorMonitor

Weight(daily)

BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUN Ca+, P Plasma transaminases

Weight(daily)

BloodDaily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status3 times/week BUN Ca+, P Plasma transaminases


Monitor—cont’dMonitor—cont’d

BloodTwice/week Ammonia Mg Plasma transaminasesWeekly Hgb Prothrombin time Zn Cu Triglycerides

BloodTwice/week Ammonia Mg Plasma transaminasesWeekly Hgb Prothrombin time Zn Cu Triglycerides


Monitor—cont’dMonitor—cont’d

Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)

Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)

Urine:Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)

Other:Volume infusate (daily)Oral intake (daily) if applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)


ProblemsProblems

PPNSite irritation

TPN1. Catheter sepsis2. Placement problems3. Metabolic

PPNSite irritation

TPN1. Catheter sepsis2. Placement problems3. Metabolic


PediatricPediatric

EnergyInfant

50 to 60 kcal/kg/day maintenance70 to 120 kcal/kg/day growth

Child >1yrBEE

1to 8 yrs 70 to 100 kcal/kg/day8 to 12 yrs 60 to 75 kcal/kg/day12 to 18 yrs 45 to 60 kcal/kg/day

Injury factors1.25 mild stress1.50 nutritional depletion2.00 high stress

EnergyInfant

50 to 60 kcal/kg/day maintenance70 to 120 kcal/kg/day growth

Child >1yrBEE

1to 8 yrs 70 to 100 kcal/kg/day8 to 12 yrs 60 to 75 kcal/kg/day12 to 18 yrs 45 to 60 kcal/kg/day

Injury factors1.25 mild stress1.50 nutritional depletion2.00 high stress


Pediatric—cont’dPediatric—cont’d

Protein:Infant

2.4 to 4 g/kg/day <1500 g weight2.0 to 2.5 g/kg/day 0 to 12 months

normal weight

Child >1 year 1 to 8 years 1.5 to 2.0 g/kg/day 8 to 15 years 1.0 to 1.5 g/kg/day

Protein:Infant

2.4 to 4 g/kg/day <1500 g weight2.0 to 2.5 g/kg/day 0 to 12 months

normal weight

Child >1 year 1 to 8 years 1.5 to 2.0 g/kg/day 8 to 15 years 1.0 to 1.5 g/kg/day



Carbohydrate Infant preterm: 4 to 6 mg/kg/minute begin rate Term infants: 8 to 9 mg/kg/minute begin rate

Fat Infants: 0.5 to 1.0 g/kg/day min for EFA needs 2 to 3 g/kg/day max

Vitamins and minerals:See tables in textbook

Carbohydrate Infant preterm: 4 to 6 mg/kg/minute begin rate Term infants: 8 to 9 mg/kg/minute begin rate

Fat Infants: 0.5 to 1.0 g/kg/day min for EFA needs 2 to 3 g/kg/day max

Vitamins and minerals:See tables in textbook



Fluid and electrolytes Infant: LBW 125 to 150 ml/kg/day

2 to 4 mmol/kg/day for electrolytes

Other infants and children

Fluid and electrolytes Infant: LBW 125 to 150 ml/kg/day

2 to 4 mmol/kg/day for electrolytes

Other infants and children


Document in ChartDocument in Chart

Type of feeding formula and tube

Method (bolus, drip, pump)

Rate and water flush

Intake energy and protein

Tolerance, complications, and corrective actions

Patient education

Type of feeding formula and tube

Method (bolus, drip, pump)

Rate and water flush

Intake energy and protein

Tolerance, complications, and corrective actions

Patient education

Enteral and Parenteral Nutrition Support Chapter 23.

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