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L12 Enteral nutrition - Coggle Diagram
L12 Enteral nutrition
Patients more likely to need enteral support
AIDS
Burns
Cancer
Prolonged infections
Kidney/Liver/Lung/Pancreas/Stomach problems
Surgery
Swallowing impairment caused by neurological/oropharyngeal dysfunction
Trauma
Prolonged vomiting
Tracheostomy
Comatose
When is nutritional support necessary?
Major trauma, burns, wounds, critical injury
Severely malnourished
Impaired digestion, absorption, metabolism
Impaired ingestion
Inability to eat adequately
Types of enteral formulas
Elemental(monomeric) or semi-elemental (oligometric) :Predigested or semi-digested nutrients, requires less digestive and absorptive capacity of gi tract
Fats: Fish oil, Medium-chain triglycerides, safflower oil, sardine oil, soybean oil, soy lecithin, structured lipids
Carb: Cornstarch, hydrolyzed cornstarch, Maltodextrin
Hydrolyzed casein, hydrolyzed whey protein, crystalline L-amino acids, Hydrolyzed lactalbumin, soy protein isolate
Modular: Single nutrient component such as protein, carbohydrate or fats, added to other feeds
Standard/polymeric: Contains intact nutrients, for patients with fully functional Gi Tract, examples: Ensure, Isocal, Isosource HN, Enercal Plus, Jevity
Carbohydrate: Corn syrup solids, hydrolyzed cornstarch, Maltodextrin, Sucrose, Fructose, Sugar alcohols
Fats: Borage oil, Canola oil, Corn oil, Fish oil, high oleic sunflower oil, Medium chain triglycerides, Menhaden oil, mono+ Diglycerides, palm kernel oil, safflower oil, soybean oil, soy lecithin, fatty acid esters
Protein: Casein, Soy protein isolate, whey protein concentrate, lactabumin, milk protein concentrate
Specialized: For specific metabolic needs
For cancer (Resource Support plus and prosure): Contains omega-3 fatty acids derived from fish oil, eicosapentanoic acid(EPA) and docosahexaenoic acid(DHA) for weight loss, anorexia and loss of skeletal muscle mass
For diabetes/glucose intolerance: Less carbs(34-40% of total calories), higher and modified fats(40-49% of total calories), 10-15g/liter of fiber for better glycemic control and prevent delayed gastric emptying. Ensure Diabetes care, Nutren diabetes and glucerna.
Renal failure: Calorically dense, electrolyte restricted for Na, K, Phosphorus, Mg. Patients w/o dialysis are protein restricted. Patients on dialysis require higher protein as dialysis removes some amino acids. Ex: Novasource Renal, Nepro LP and Nepro Hp, Suplena.
Respiratory quotient is volume of CO2 released over vol of O2 during respiration. RQ for fat, protein and carbs oxidation are 0.7,0.8 and 1.0 respectively. Therefore, feeds for patients with pulmonary failure or respiratory distress typically contain more fats and less carbs to reduce CO2 production. Ex: Pulmocare, Nutren pulmonary and Oxepa.
Energy, protein, Vitamin A, C, E, zinc and arginine all are linked to wound healing, thus feeds need to contain 15-400% of recommended dietary intake, along with high calorie and protein formula. Example: NutriHeal, Replete and Replete Fiber, Resource Arginaid, Juven and Promote.
Fiber containing feeds for altered bowel function. Soluble fiber may help with diarrhoea by increasing colonic sodium and water absorption, while soluble fiber provides bulk to stool, but sufficient H2O is still needed for constipation. Example of feeds: Replete Fiber and Jevity.
Calorie dense feeds for fluid restricted patients, ranges from 1.2-2 kilocalories per ml. Example Nutrien 1.5 and Nutrien 2.0, Jevity 1.2 and 1.5, Resource 2.0 and TwoCal Hn.
How to decide on enteral feed?
Medical conditions
Caloric requirement-> look at physical activity and physiological status of patient to not over-feed and cause weight gain.
Digestive and absorptive capacity of GI tract function
Fluid restriction
Food allergy
Cost
Complications(After starting enteral feeding, what may happen unexpectantly?)
Gastrointestinal-> Diarrhoea, Constipation, Nausea/vomiting, Dumping syndrome
Mechanical-> Pulmonary aspiration, Tube obstruction, Tube malposition, Mucosal damage
Metabolic-> Overhydration/dehydration, Hyperglycemia/Hypoglycemia, Hyperkalemia/Hypokalemia, Hyperphosphatemia/Hypophosphatemia, Excessive/inadequate weight gain, Elevated Blood urea nitrogen, Hyponatremia (low sodium), Hypomagnesemia
Refeeding syndrome(low Mg, low phosphate, low potassium, increased intravascular volume, and less commonly Wernicke's encephalitis), this can lead to arrhythmias, respiratory and cardiac failure, aspiration and death
Factors to monitor for feed suitability
Tolerance-> Signs of intolerance are nausea/vomiting, diarrhoea, abdominal distension(swelling of abdomen),
Daily weight
Input/output records
Serum electrolytes
Blood urea nitrogen
Liver function tests
Parenteral Nutrition
Provision of nutrients via intravenous administration
For patients who cannot eat or absorb enough nutrients through tube feeding or mouth
Total parental nutrition (TPN) or central PN
Preferred use for patients for longer than 7-14 days, suitable for patients with fluid restriction
Peripheral parental nutrition (PPN)
For patients with mild to moderate malnutrition for up to 2 weeks because of limited tolerance and few suitable peripheral veins
Are liquid formulations preferred in tube feeding?
Usually preferred except if formulation contains other ingredients that causes unwanted S/E, or if it's inappropriate, viscous liquid medications may need dilution, Elixirs/suspensions preferred as syrups may cause clumping.
Most simple,compressed tablets are sugar/flim-coated, immediate release and may be crushed, crushed with mortar and pestle, mixed with 15-30mL of H2O before tube delivery. Capsules may be opened, capsules with powdered drugs are mixed in 10-15mL of H2O before tube delivery, Liquid-filled gelatin can be poked with needle and contents are mixed with water, granules can be emptied into feeding tube.
Feeding tube should be flushed with 5-10mL of water between drugs if >1 drug is administered.
When to administer the drugs?
On bolus/intermittent gastric feedings, drugs may be administered between feedings.
If on continuous feeding, pause feeding 2 hours before drugs and restart 2 hours after. Feeding rate is to be adjusted to compensate for time feed paused.
Enteral feeding routes
Nasoenteric feeding
For short term enteral support (<4 weeks)
Nasoduodenal- From nasal cavity to duodenum
Nasojejunal- Nasal cavity to jejunum
Nasogastric
Enterostomy feeding
used when enteral support >4 weeks, and in clinical situations with high risk for aspiration pneumonia
Endoscopic gastrostomy and Endoscopic Jejunostomy
Pros and cons
Pros
Provide nutrition, Monitor intake easily and accurately, Preserve gut integrity especially immunological function of gut, decrease bacterial translocation, fewer infectious complications in critically ill patients, reduce risks associated with disease state, readily available in pharmacies, safer.
Cons
GI Tract, metabolic and mechanical complications, cost more than oral diets, poor patient acceptance, Administration, assessment, site care and monitoring are labour intensive
When is enteral nutrition not suitable?
If only required for very short duration, risks of starting enteral nutrition may outweigh the benefits
Contraindications: Non-operative mechanical GI tract obstruction, intractable vomiting/diarrhoea resistant to medical management, severe short bowel syndrome, Paralytic ileus-when motor activity of bowel is impaired, severe GI bleeding, Severe GI Tract malabsorption-when gut cannot absorb nutrients, inability to gain access to GI Tract
How is enteral nutrition administered?
Bolus/intermittent feeding
Mimics a meal, larger amt of feed given in a short period of time (usually<30 min, flush tube with 20-30ml of warm water after feeding, 250ml of Ensure 5x a day)
Continuous feeding
Flow rate expressed as ml/hr, important to ensure patient can tolerate feeds, requires feeding pump, flush tube with 20-30ml of warm water every 4 hours, 50ml/h of Ensure
Macronutrients
Carbohydrates, Proteins, Fats
Micronutrients
Vitamins and minerals that help in growth development and repair
Enteral vs parenteral
Functional GI tract? Yes- Enteral nutrition, No-Parenteral nutrition
Is the delivery of nutrients beyond oesophagus via feeding tubes, catheter or stoma, and the oral intake of dietary foods for special medical purposes