ENTERAL and PARENTERAL FEEDING Mylin G. Abalus NUTN 204 Lecturer

OBJECTIVES

LESSON OVERVIEW

Enteral Nutrition Form of feeding that brings nutrients directly into the digestive tract Oral feeding Tube feeding- feeding by tube directly into the stomach or intensive or via a vein

Enteral Nutrition Indicated for patients who have a functioning GIT but can’t ingest enough nutrients orally Advantages: Better preservation of the structure and function of GIT Lower cost Fewer complications, particularly infections Indications: Prolonged anorexia Severe protein-energy undernutrition Coma or depressed sensorium Liver failure Inability to take oral feedings Critical illnesses Malabsorption problems

Types of Feeding Tubes Nasogastric (NG) tube inserted through the nose and into the stomach and small intestine For periods that do not exceed 6 weeks Percutaneous Endoscopic Gastrostomy (PEG) tube For periods > 6 weeks Opening called an “ostomy” is needed (esophagostomy, gastrostomy, jejunostomy)

Types of Enteral Formulas POLYMERIC FORMULA Commercially prepared formulas that provides complete, balance diet 1-2 calories/ml Contains proteins, carbohydrates, and fats Requires digestion Blenderized food and milk-based or lactose free commercial formula

Types of Enteral Formulas ELEMENTAL or HYDROLYZED FORMULAS Formula containing products of digestion of proteins, carbohydrates and fats Used for clients who have difficulty digesting food Provide 1 cal/ ml; lactose-free Expensive and usually unnecessary e.g. amino acid formula, calorie- and protein-dense formula, restricted, fiber-enriched formula

Types of Enteral Formulas MODULAR FORMULAS (Feeding modules) Provides 3.8- 4 cal/ml Can be used as supplements to other formulas or for developing customized formulas for certain clients (e.g. burn patients) Usually used in acute setting and for short period of time (e.g. renal failure, respiratory failure, liver failure) May contain specific nutrient; used to treat specific deficiency or combines with other formulas

Three Methods of Administering Tube Feedings Intermittent Bolus Continuous Administering tube feedings usually at night; solid foods eaten during the day Daily calorie needs are divided into 6 servings/day (< 400 ml); given over 15 mins followed by 25-60 ml of water Feedings are administered by a continuous pump; 16- to 24-hour period; initially at a rate of 30-50 ml/per

Guidelines in Administering Tube Feedings Nasogastric or nasoduodenal tube feeding Jejunostomy tube feeding NGT feeding often causes diarrhea Usually started with small amounts of dilute preparations Solution may be given undiluted at 50 ml/hour Water boluses may be given Note: Higher caloric formula may cause decreased gastric emptying  higher residual than more dilute formula Requires greater dilution and smaller volumes Feeding usually begins at < 0.5 kcal/ml and a rate of 25 ml/h Concentrations and volumes is increased after few days

Complications of Enteral Tube Nutrition PROBLEM CAUSE EFFECT 1. Presence of tube Tube irritates tissues causing them to erode Damage to the nose, pharynx or esophagus 2. Blockage of tube lumen Thick feedings or pills can block the lumen Inadequate feeding 3. Misplacement of nasogastric tube intracranially Tube may be misplaced intracranially if the cribriform plate is disrupted by severe facial trauma Brain trauma, infection

Complications of Enteral Tube Nutrition PROBLEM CAUSE EFFECT 4. Misplacement of naso- or orogastric tube in the tracheobronchial tree Responsive patients- cough and gag Obtunded patients- may have few immediate symptoms Pneumonia 5. Dislodgement of gastrostomy or jejunostomy tube Tube may be displaced into the peritoneal cavity Peritonitis

Complications of Enteral Tube Nutrition PROBLEM CAUSE EFFECT 6. Intolerance of one of the formula’s main nutrient components *usually occurs with bolus feedings *lactose Diarrhea, GI discomfort, nausea, vomiting 7. Osmotic diarrhea High osmolality of the solution *Sorbitol- often contained in liquid drug preparations *Clostridium difficile Weakness, diarrhea 8. Nutrient imbalances Specific formulas Electrolytes disturbances, hyperglycemia,

Complications of Enteral Tube Nutrition PROBLEM CAUSE EFFECT 9. Reflux of solutions Clogged tube or tube may be pulled out ASPIRATION

Parenteral Nutrition Provision of nutrients intravenously Used if GIT is not functional or normal feeding is not adequate Compared with enteral feeding, it causes more complications, does not preserve GIT structure and function and more expensive Solutions- prescribed by physician and dietitian and prepared by pharmacist Administered via CENTRAL or PERIPHERAL VEIN

Parenteral Nutrition Peripheral Vein Central Vein 2 weeks or less Subclavian or superior vena cava is used Indications: Some stages of Crohn’s disease or ulcerative colitis Bowel obstruction Certain pediatric GI disorders (congenital anomalies, prolonged diarrhea) Short bowel syndrome

Types of Parenteral Nutrition Partial Parenteral Nutrition Supplies only part of daily nutritional requirements, supplementing oral intake Dextrose or amino acids solutions Total Parenteral Nutrition (Hyperalimentation) Supplies all daily nutritional requirements TPN solutions are highly concentration- central vein is used

Parenteral Nutrition Content water 30-40 ml/kg/day energy 30-60 kcal/kg/day (depending on energy expenditure) Amino acids 1-2 g/kg/day Essential fatty acids Vitamins minerals Standard TPN solution- 2 L Most calories are supplied by CHO (25% dextrose) May also have lipid emulsions to supply essential fatty acids and triglycerides 20-30% of total cal supplied from lipids Electrolytes may be added Modified based on results, d/o

Parenteral Nutrition Solutions Reduced protein content and high percentage of essential amino acid- renal failure or liver failure Limited volume (liquid) intake- heart or kidney failure Lipid emulsion (provides non-CHON calories minimize CO2 production by CHO metabolism)- respiratory failure

Guidelines in Caring for Patient having Parenteral Nutrition Strict sterile technique during insertion and maintenance of central venous catheter TPN line should not be used for any other purpose External tubing should be change every 24 hours Dressing should be kept sterile and changed every 48 h using strict sterile technique

Guidelines in Administering Parenteral Nutrition Solution is started slowly at 50% calculated requirements + 5% dextrose Energy and nitrogen given simultaneously Amount of regular insulin (added directly to the TPN solution) depends on the serum glucose level (e.g. level is normal; 25% dextrose= 5-10 units of regular insulin)

Guidelines in Caring for Patient having Parenteral Nutrition Monitor weight, CBC, electrolytes and BUN Serum glucose monitored every 6 h until stable Monitor intake and output Monitor liver function test Measure plasma CHONs (albumin), prothrombine time, plasma and urine osmolality, Ca, Mg and phosphate twice a week Full nutritional assessment (BMI) every 2 weeks

Complications of Parenteral Nutrition Catheter related sepsis Phlebitis/thrombosis Glucose abnormalities Hepatic complications Abnormalities of serum electrolytes and minerals Volume overload Bone demineralization Gallbladder complications