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
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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/universi13
 Novartis Nutrition USA
http://www.novartisnutrition.com/us/home
 Abbot Nutrition Product Handbook
http://abbottnutrition.com/productHandbook/
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, Fibersource HN,
Enteral Selection
 Extra calories/volume restricted
– Osmolite 1.2, TwoCal HN, Novasource 2.0,
Nutren 1.5, Nutren 2.0, Peptamen 1.5, Jevity
1.2, Jevity 1.5
 High nitrogen
– Osmolite HN, TwoCal 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
– NutriHep (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
Copyright © 2000 by W. B. Saunders Company. All rights reserved.
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
(mOsm/kg)
Osmolality
 Isotonic formula = osmolality ~300 mOsm
 Body attempts to restore the 280 – 300 mOsm
 Enteral feedings range from < 300 – 700
mOsm/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
mOsm/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 are
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/mL = standard formula
• 1.5-2 kcal/mL = 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. 5th 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 1st 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 10th 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:
• 1kcal/ml = ~85% free water (850mL per 1,000 mL
formula)
• 1.2-1.5 kcal/mL = 69% - 82% (690-820)
• 1.5-2.0 kcal/mL = 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 mL water with
continuous feeds
– Irrigate tubes before and after each intermittent
or bolus feed with 20-60 mL water
– In case of clogging, tube should be flushed
using 60mL syringe with 30-60 mL 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:
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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 2x 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 (mL)
Diet
Saliva
Stomach
Pancreas/Bile
Intestine
Subtractions (mL)
Colointestinal
Net stool loss
2000
1500
2500
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 mL
 Consider stopping RV checks in stable pts
Rees Parrish C. Enteral Feeding: The Art and the Science. Nutr
Clin Pract 2003; 18;75-85.