Enteral nutrition finall

Calories Calculation
BMR(male) = 66 + (13.7 x W in kgs.) + (5 x H in
cms.) - (6.8 x Age in yrs.)

Activity
Factors
Values
Stress Factors
Values
Sedentary 1.2 Fever 1.2
Active 1.3 Sepsis 1.3
Cancer 1.6
Surgery 1.0
Starvation 0.70
20% Burn 1.0 – 1.5
40% Burn 1.5 – 1.8
40% - 100%
Burn
1.8 – 2.0

Indications for tube feeding:
Comatose patient
Severely debilitated
Patients who have gone undergone
radical facial or neck surgery.
Oral intake is inadequate or
contraindicated
Increased nutritional requirements

Polymeric formulas
Oligomeric formulas

Composed of intact proteins, disaccharides and
polysaccharides and variable amount of fat.
Similar to average diet.
Calorie density 1kcal/ml
Nitrogen concentration of 5-7g/1000ml
 Requires an intact gut for digestion.
Also includes disease specific formulas.
Lactose free and most are gluten free
Can be used orally also .
Examples are ISOCAL, ENSURE, GLUCERNA etc

CALORIC DENSE FORMULAS
 2 kcal/ml or 1.5 cal/ml
 Fluid restriction, Volume
intolerance, Electrolyte
abnormalities
 Examples are Novasource
Renal, Suplena, Ensure plus
FIBER CONTANING FORMULAS
 Fiber 5 -15g/L
 For regulation of bowel
movement
 Examples are Ensure,
Glucerna

 RENAL FORMULA
 Calorie dense, low electrolytes,
vary in proteins
 Renal failure
 Target to minimize BUN reduce
accumulation of toxic waste ,
maintain electrolyte & water
balance .
 Examples are NOVASOURCE
RENAL, SUPLENA

 HEPATIC FORMULA
 High in BCAA, low in AA, low in
electrolytes.
 Hepatic failure, encephalopathy
 Reduced in aromatic amino
acids & methionine , so as to
correct abnormal plasma ratio
of theses amino acid.
 Example is SUPLENA

 DIABETIC FORMULA
 Low in CHO
 High fiber content.
 Sucrose free
 Example Glucerna, Glucerna SR,
Boost Diabetic

 PULMONARY FORMULA
 Deterioration of nutritional
status in critically ill patients
with respiratory insufficiency is
associated with
reduction of respiratory
muscle mass
problems in weaning from
vent ,
 Patient tend to retain Co2. Can
be corrected by using formula
with higher fat than CHO ratio
 Example is PULMONARY
FORMULA

IMMUNE ENHANCING
FORMULA
Metabolic stress, immune
dysfunction.
Arginine, glutamine, omega 3 FA,
anti oxidants
Examples are ENSURE PLUS,
IMPACT

OLIGOMERIC FORMULAS
Elemental formula
Partially hydrolyzed.
Hyperosmolar
Contains nitrogen in the form of free
amino acids or peptides.
Impaired digestive and absorptive capacity
Example is VITAL HN, PEPTAMEN

Selection of appropriate
formula should be based on
the individual patient’s:
Medical and nutritional status
Digestive and absorptive
capabilities
Individual nutrient
requirements

Methods of Feeding
Continuous infusion
Intermittent infusion
Bolus feeding

 Continuous Feeding
 Begin undiluted feeding at a rate
between 10 and 50ml/hr.
Greater doubts about GI functions
should prompt lower infusion rates.
 Increased the rate in increments of
20-40ml/hr, every 8-24hrs to attain
the required rate( calculated to
meet energy and protein
requirements), in as little as 1 day
or as many as 5 days, depending on
the state of GI tract.
 The final rate should not exceed
125-150 ml/hr: high nutrient
requirement should met with 1.5-2
kcal/ml formulas.

Discontinue enteral feeding only
when adequate oral intake has been
achieved.
When the likelihood of achieving oral
intake is uncertain, use weaning
methods such as
reducing the infusion rate,
interrupting the infusion before
meals
 infusing only at night to improve
appetite and oral intake during the
day.

 Bolus Feeding
 Begin with 50-100ml boluses of
undiluted feeding every 2-4 hrs.
Increase the size of boluses every 8-24
hrs, to 100ml, 150ml, 200ml. Etc. until
requirements are met.
 In alert patients it is often possible to
begun with 250ml boluses and increase
the volume to as high as
400ml/feeding. If possible avoid
feeding during the night.
 If water requirements are not met by
the formula, additional water should be
given with the flush.
 Wean patients to oral intake by
eliminating feedings that precede
meals. Discontinue enteral feedings
only when adequate oral intake has
been achieved.
Ref:Douglas C. Hemiburger, Jamy D. Ard “Hand Book
Of Clinical Nutrition”, 3rd edition 2006, page no. 319

All orders for tube feeding must
include the following information
Formula
Formula volume per feeding (ml
only) and total formula volume/24 hrs
Frequency of feedings
Additives ( carbohydrate or protein
powders, etc.: Amount added to
each feeding in table spoons, tea
spoons, ml or ounces and total
amount per 24 hrs) cont.

 Tube Type (G.T., N.G. or J.J.)
 Feeding Method: Pump (including
administration rate), bolus or
Gravity (number of minutes for
feeding)
 Flushes ( feeding and medication)
before, after or both
Ref: ‘DIET MANUAL’ State of California Dept
of Development Services, 2003. Revised
2004&2009

 GASTROINTESTINAL COMLICATIONS
1. Diarrhea
 Causes
 Hypertonic feeding formulas
 Hypoalbunemia
 Bacterial contamination
 Inadequate fiber in feeding
formulas
 Certain infusion methods (e.g.
bolus infusions or rapid increases in
infusion rates)
 Medications
 Elixir medications containing
sorbitol
Magnesium containing antacids
Oral antibiotics (definite); IV
antibiotics?, Phosphorous supplements,
histamine-2 receptor blockers,
metaclopramide, other assorted
medications.

Do’s
 Carefully review all medications
 Eliminate all elixirs containing sorbitol
 Eliminate Mg containing antacids
 Eliminate any other potential offenders
 Consider giving psyllium (ispaghol) or pectin.
Don'ts
 Don’t stop the feeding any longer than is
necessary to determine whether it is causing
diarrhea.
 Don’t change the feeding formula with the
assumption that doing so will relieve the
diarrhea
Ref: Douglas C. Hemiburger, Jamy D. Ard “Hand Book Of Clinical
Nutrition” 2006 page no. 322,

 Causes:
 Inactivity
 Decreased bowel
motility
 Decreased fluid
intake
 Lack of dietary fiber
 Poor bowel motility
and
 Dehydration
 Treatment
 Bowel stimulants
 Adequate hydration
 Use of fiber-
containing formulas
 Stool softeners

 Causes
 Delayed gastric emptying
 Abdominal distention
 Treatment
 Reducing narcotic
medications
 Switching to a low-fat
formula
 Administering the feeding
solution at room
temperature
 Reducing the rate of
administration
 Administering a
promotility
 Check gastric residuals before
the next bolus feeding, or
every four hours for
continuous feeding.
 If gastric residuals are low
yet nausea persists, consider
antiemetic medications.

1) Aspiration
Risk factors for aspiration
include:
 Decreased level of consciousness
 Diminished gag reflex
 Neurologic injury
 GI reflux
 Supine position
 Use of large-bore feeding tubes
 Large gastric residuals
Use of small-bore feeding tubes,
promotility agents, periodic
assessment of gastric residuals,
and keeping the head of the bed
elevated may reduce the risk of
aspiration
2)Tube malposition
3)Tube Clogging

POSSIBLE ETIOLOGY POSSIBLE CAUSE POSSIBLE TREATMENT
Hyponatremia Excessive free water,
Abnormal sodium loss
Change to fluid
restricted formula,
Discontinue water
boluses, replace sodium
losses
Hypernatremia Inadequate hydration,
Increased fluid loses,
Diabetic Insipidus
Add or increase water
boluses or IVF
Hypokalemia Anabolism, refeeding,
diuretics, medications
Supplement K
Hyperkalemia Renal failure,
metabolic acidosis,
catabolism, GI bleed,
acute dehydration
Correct imbalance
Change to renal formula
as appropriate

POSSIBLE ETIOLOGY POSSIBLE CAUSE POSSIBLE TREATMENT
Hypophosphatemia Anabolism
Refeeding
Supplement Phosphorus
Hyperphospatemia Renal failure Change to renal formula
Phosphate binders
Hypomagnesimia Anabolism, refeeding,
diuretics, medications
Supplement Mg
Hyperglycemia Diabetes,
Steroid therapy,
Sepsis, Trauma,
Pancreatitis
Change to diabetic
formula
Insulin drip per
protocol
Goal is to maintain
blood glucose at or <
110 mg/dl
Ref: ‘ Enteral feeding guidelines, Harbor view Medical Centre, Katie Farver, RD, CD

Enteral nutrition finall

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