TNT Session 8
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Transcript of TNT Session 8
Implementing Enteral Implementing Enteral Nutrition: Formula Nutrition: Formula
Selection and Selection and AdministrationAdministration
Objectives
• To describe the categories of enteral formulas• To explain how to choose the appropriate category of
enteral formula for each patient’s disease state• To describe the various methods for delivering
enteral nutrition and how to choose the most appropriate formula for each situation
Enteral Formulas: Categories
• Polymeric formulas– Commercial– Blenderized
• Oligomeric formulas • Disease-specific formulas • Modular formulas (concentrated protein and
carbohydrate preparations)
Polymeric FormulasContain intact macronutrients and require digestion: Intact proteins Polysaccharides Disaccharides Polyunsaturated fatty acids (PUFA) Medium-chain triglycerides (MCT)
Polymeric Formulas:Benefits of Commercial Formulas Commercial Formulas Blenderized Formulas
Uniform contentsSterile
Low viscosityLactose freeDefined caloric density
Daily nutrient variabilityNon-sterile; high bacterial content and other pathogensHigh viscosityDoes not provide adequate caloric density
Gallagher-Allred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50Sullivan MM, et al. J Hosp Infect 2001;49:268-273
Commercial Polymeric Formulas: Selection
Features• Protein, caloric density, and osmolality vary• With or without added fiber• Most are lactose- and gluten-free• Nutritionally complete in sufficient quantities
Patient must have:• Functional GI tract• Normal digestion• Normal absorption
Oligomeric Formula CategoriesHydrolyzed macronutrients facilitate digestion and absorptionComponents
Amino acids– Glutamine– Arginine
PeptidesMonosaccharides Disaccharides
Also called “elemental,” “semi-elemental,” “hydrolyzed”, or “chemically defined” formula.
In: Rombeau JL, Rolandelli RH, eds. Clinical Nutrition: Enteral and Tube Feeding. 3rd ed. WB Saunders Company; 1997
Glucose polymers
Polyunsaturated fatty acids
Medium-chain triglycerides
Vitamins and minerals
Oligomeric Formulas: SelectionIndications for Use:• Inflammatory bowel disease• Pancreatic insufficiency• Malabsorption • Short bowel syndrome• Radiation enteritis• Early enteral feeding • Intolerance to polymeric formula
Enteral Formula Selection: Disease-Specific Formulas• Pulmonary disease• Glucose intolerance• Cancer-induced weight loss• Hepatic insufficiency • Critical care• Renal failure• HIV+/AIDS
Cabre E, Gassull MA. Nutrition 1992;8:1-9.
Disease-Specific Formula Selection:Pulmonary Disease (Chronic)
Pulmonary disease with CO2 retention
• Decreased carbohydrate content• Increased fat content• High caloric density• Intact proteins• Fiber supplement
Brown RO et al. Clin Phar 1984;3:152-161; Askanazi J et al. Anesthesiology 1981;54:373-377Deitel M et al. J Am Coll Nut 1983;2:25-32
Disease-Specific Formula Selection:Glucose IntoleranceGlucose Intolerance• Diabetes mellitus
– Type I – Type II
• Hyperglycemia associated with: – Pancreatic disease – Drug and chemical-induced – Insulin receptor abnormalities
– Hormonal alterations– Genetic syndromes– Metabolic stress
Cabre E, Gassull MA. Nutrition 1992;8:1-9
Disease-Specific Formula Selection:Glucose Intolerance
Recommendations• Low carbohydrate content
– Monosaccharides (fructose)– Glucose polymers
• Increased monounsaturated fat (MUFA)• Added fiber
Franz MJ, et al. Diabetes Care 1994;17:490-518; J Am Diet Assoc 1994;94:504-506Diabetes Care 1997;20:514-517
Disease-Specific Formula Selection:Cancer-Induced Weight LossCancer-Induced Weight Loss• Complex metabolic syndrome - anorexia, fatigue,
early satiety• Significant weight loss & muscle wasting• Etiology is multifactorial
– Pro-inflammatory cytokines – Acute phase response– Abnormal metabolism– Proteolysis inducing factor (PIF)
• Cannot correct by additional calories alone
Negative Prognosis
&QOL
Disease-Specific Formula Selection:Cancer-Induced Weight LossRecommendations• High protein and Zn to build muscle • Low fat to avoid early satiety• Low in sucrose for better patient acceptance• High in fermentable fibers• Eicosapentaenoic acid (EPA) • Antioxidants (vitamins A, C, E and Se)• Folate and iron for anemia
Disease-Specific Formula Selection:Hepatic Disease
Hepatic Insufficiency• Altered protein metabolism and protein loss• Altered carbohydrate metabolism
– glucose intolerance– low hepatic glycogen stores
• Malabsorption of fat and fat-soluble vitamins• Inability to elongate or desaturate essential fatty acids• Vitamin and mineral deficiencies (e.g., B-complex and Zn)• Impaired urea synthesis with hyperammonemia and hepatic
encephalopathy• Fluid and sodium retention• Reduced appetite/oral intake and taste impairment
Disease-Specific Formula Selection:Hepatic Disease
Recommendations• High caloric density with low sodium content• Moderately high calorie:nitrogen ratio• High in branched chain AAs and low in aromatic AAs• Non-digestible soluble fiber • Long-chain fatty acids and supplemental MCT• Supplemented with fat soluble vitamins, Zn, folic acid and B
complex vitamins• Low copper, iron, manganese content
Disease-Specific Formula Selection:Critical Care
Types of Injury• Elective surgery• Minor trauma• Burn• Pressure ulcer
Patient Conditions• Sepsis• Inflammatory
Disease-Specific Formula Selection:Critical CareNutrient Choices• Hydrolyzed or intact proteins• Glutamine• Arginine• Taurine, Carnitine• Eicosapentaenoic acid (EPA), Gamma-linolenic Acid (GLA)• Antioxidants
Poullain et al. JPEN 1989;13:382-386; Lacey JM et al. Nutr Rev 1990;48:297-309 Barbul A et al. Surgery 1990;108:331-337
Disease-Specific Formula Selection:Critical Care (Mechanical Ventilation)Lung Injury / SIRS / ARDS• Eicosapentaenoic acid (EPA) • Gamma-linolenic Acid (GLA)• Antioxidants• High caloric density• No arginine supplementation
Gadek J. Chest 1998;114:277S; Gadek J. Crit Care Med 1999;27:1409-1420; Pacht ER, et al. Crit Care Med 2003;31:491-500
Disease-Specific Formula Selection:Critical CareArginine (a double-edged sword)• Conditionally essential nutrient that enhances wound
healing• Supports immune system and is associated with
reduced infectious complications
“Giving arginine to a septic patient is like putting gasoline on an already burning fire.”
- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL
Disease-Specific Formula Selection:Renal Disease
Acute or Chronic Renal Disease• Increased BUN and creatinine• Increase in serum electrolytes:
– Na – K – PO4
– Mg
Kopple JD. In: Shils ME et al eds. Modern Nutrition in Health and Disease. 8th ed. Philadelphia: Lea & Febiger; 1994:1102-1134; Blumenkranz MJ et al. Kidney Int 1982;21:849-851
Disease-Specific Formula Selection:Renal DiseaseRecommendations• Protein content
– Predialysis: 30 g/L – Dialysis: 70 g/L
• Low electrolyte content• High caloric density
Monson P, et al. J Renal Nutr 1994;4:58-77 ASPEN Board of Directors. JPEN 2002;26 Suppl 1
Disease-Specific Formula Selection:Advanced AIDS (with weight loss)Advanced AIDS
• Weight loss > 5% below normal• CD4 < 400• Serum albumin < 3.0 g/dL• Opportunistic infection• Diarrhea• Impaired immune function
Raiten DJ. Nutrition and HIV Infection. Department of Health and Human Services, Washington D.C.Grunfeld C et al. Sem Gastro Dis 1991; Kotler DP et al. Am J Clin Nutr 1985
Disease-Specific Formula Selection:Advanced AIDS (with weight loss)
Recommendations• Increased protein• Low fat for improved tolerance• Added fiber• EPA to down regulate metabolic changes associated
with cachexia• Increased levels of antioxidants (beta-carotene, vitamin
E, C) and B vitamins (B6, B12)
Baum MK, et al. Ann N Y Acad Sci 1992;669:165-174Raiten DJ. Nutrition and HIV Infection. Dept. of Health and Human Services , Washington D.C.
Enteral Formula: Selection
• Metabolic requirements• Patient condition or status• Pre-existing conditions• GI function
Enteral Formula: Selection
• The physician should know the formula’s nutrient profile to meet specific patient needs
• Understand the clinical evidence supporting specific formula use
• Data obtained exclusively from animal models may or may not apply to the clinical setting
Enteral Formula: Oral AdministrationOral Supplementation• Indicated especially for patients with malnutrition or at risk
for weight loss• When given between meals, does not reduce intake of
other foods
• Frequently stimulates increased intake of other foods• Thickened oral supplements are useful for patients with
dysphagia
Benefits of Oral SupplementsImprovement in Oral Intake
Prop
ortio
nal I
ncre
ase
Delmi M et al. Lancet 1990;335:1013-1016
0
50
100
150
200
250
Daily Energy(kcal)
Daily Protein (g) Daily Calcium(mg)
Without SupplementWith Supplement
Enteral Formula: Tube FeedingType:• Intermittent • Continuous:
– 24 hours / day – During part of the day or at night
Infusion Method:• Gravity• Infusion pump
Gottschlich MN, Shronts EP, et al. Defined formula diets. In: Rombeau JL, Rolandelli, eds. Clinical Nutrition: Enteral and Tube Feeding. W B Saunders; 1997; Giocon JO et al. JPEN 1992;16:525-528
Enteral Formula: AdministrationEnteral FeedingIntermittent• Resembles normal feeding and digestion patterns• 250-500 mL of formula• Administered over 30-60 minutes• 5-8 times daily
Enteral Formula: AdministrationContinuousPlan 1Beginning: Day 1: 1000 mL over 24 hoursProgress: Day 2: 1500 mL over 24 hours
Day 3: final volume according to needsPlan 2Beginning: 25 mL/h (first 12 hours)Progress: 50 mL/h for next 12 hours
rate according to needs
Enteral Formula: Administration Infusion Pump
Indications
Small intestine feeding
Fluid restrictions
Risk of aspiration
Need for precise flow rate
Nocturnal feeding
Infants and small children
Gravity InfusionIndications
Suitable for intermittent feeding
Ambulatory patients
Gastric feeding
Enteral Formula: Administration
Summary
• Intermittent feeding • Continuous feeding
ASPEN Board of Directors. JPEN 2002;26 Suppl 1: 34SA.
Summary
• Described the categories of enteral formulas • Explained how to select appropriate formulas • Described the methods of enteral nutrition
administration