1. Enteral Nutrition Support Intern Class Day December 7 th, 2015 Christina DiSegna, MS, RD, LDN, CNSC Senior Inpatient Clinical Dietitian Brigham and Women’s Hospital

2. Outline Brief History of Enteral Nutrition Indications/ Contraindications When to feed Type of access Formula selection Feeding regimen Monitoring tolerance Complications Case studies

3. History of Enteral Nutrition Used as early as the 18 th century Individuals who were unable or unwilling to consume adequate amounts of food were fed via wooden or glass tubes Dangerous and only used as a last resort Formulas were primitive Broth, milk, eggs

4. History of Enteral Nutrition With the advent of modern medicine we began to see advances in technology and formulas for EN However EN technology has developed slowly Development of parenteral nutrition in the 1960’s led to underutilization of EN for some time

5. Enteral vs Parenteral Nutrition “If the gut works, use it.” Enteral nutrition has been proven safer and more cost effective than parenteral nutrition in many settings Fewer complications associated with enteral nutrition when compared to parenteral nutrition Enteral nutrition preserves intestinal function

6. Indications for Enteral Nutrition Failure to meet energy needs with voluntary oral intake ◦ Impaired ability to ingest food ◦ Alterations in nutrient requirements ◦ Alterations in digestion and absorption ◦ Comatose state ◦ Mechanical ventilation ◦ GI failure- i.e. SBS ◦ Chronic illness, significant weight loss, and signs of macro & micro nutrient deficiencies

7. Absolute Contraindications to EN Diffuse peritonitis Gastrointestinal ischemia Intestinal perforation Distal small bowel or large bowel obstruction Unable to obtain enteral access Hemodynamic instability

8. Potential Contraindications to EN Malnourished patient expected to eat within 5-7 days High output proximal fistula Intractable nausea and vomiting Malabsorption Ileus Aggressive therapy/nutrition support is not warranted Some patients may require simultaneous EN and TPN support

9. When to Feed Evaluated bowel function Bowel sounds—absence does not preclude safe start of enteral nutrition Paralytic ileus Absence of flatus or bowel movements Ileus affects different areas of the intestine NGT in place for decompression Consider starting enteral nutrition Presence of soft, non tender abdomen Good perfusion of extremities Hemodynamic stability

10. Question 1 Which patient would be an appropriate candidate for enteral nutrition support? A. Severe neurological impairment B. Post uncomplicated colonic resection C. Short bowel syndrome D. A and C

11. Gastric vs Small Bowel Feeding Advantages to gastric feeds Tubes are easier to place and replace Large bore tubes help prevent occlusions Infusion pumps may not be necessary over the long term

12. Small Bowel Feeding Small bowel feeding may be an alternative if small intestine and colon functioning Consider small bowel feeds Gastroparesis, gastric ileus Significant gastroesophageal reflux Recent stomach surgery Pancreatitis High risk for aspiration Gastric outlet obstruction

13. Short Term Access Nasogastric tube (NGT) Considerations Need functioning stomach Can use large or small bore tubes Smaller tubes clog more easily Radiographic confirmation of placement Benefits Easily inserted and replaced Large bore tubes can accommodate medications, benefiber, protein supplements Large bore tubes are better for checking residuals

14. Short Term Access Nasoenteric tube Considerations Use in patients with aspiration risk, poor gastric emptying, or gastroparesis Cannot check gastric residuals Requires continuous or cycled infusion Benefits Some tubes allow decompression of the stomach while feeding into the small bowel

15. Long Term Access Gastrostomy (G-tube) Open surgical procedure or PEG Considerations Not optimal choice for patients with ascites, gastric emptying issues, or history of reflux Benefits Allows for bolus feeding which is physiologically normal Can be converted to jejunal feeding if necessary

16. Long Term Access Jejunostomy (J-tube): Surgically or endoscopically placed Considerations Requires continuous/cycle infusion Use in patients at risk for aspiration, gastroparesis, or s/p esophagectomy Cannot check gastric residuals Benefits May reduce aspiration risk of TF formula Can be used for patients with intermittent nausea/vomiting

17. Long Term Access Transgastric jejunostomy ◦ Considerations Requies continuous infusion Can use in patients with poor gastric emptying, gastroparesis, post-op ileus Cannot check residuals ◦ Benefits May reduce aspiration of TF formula Allow decompression of the stomach while feeding small bowel Can be converted to gastric tube later

18. Question 2 45 yo male with history of poorly controlled diabetes, admits with nausea and vomiting x several months, complains of early satiety and significant weight loss. Symptoms are not resolved with promotility agents. Should a feeding tube be placed? If so, what type and why?

19. Choosing an Appropriate Formula Categories of Enteral Formula Monomeric: predigested nutrients; must have low fat content or high % of MCT’s; for use in patients with impaired GI function Polymeric: intact proteins, use for patients with normal or near normal GI function Disease specific: for use in specific disease states

20. Monomeric Formula Examples Vivonex (Nestle) Elemental nutrition (“pre-digested”) Low fat Hyperosmolar Perative (Abbott) or Peptamen (Nestle) Semi-elemental May be indicated with malabsorptive disorders

21. Polymeric Formula Examples Two Cal HN (Abbott) or Nutren 2.0 (Nestle) Most concentrated at 2 cal/mL, hyperosmolar Osmolite (Abbott) or Nutren (Nestle) Standard formula 1 cal/mL (isotonic); 1.2 cal/mL; 1.5 cal/mL Jevity (Abbott) or Nutren 1.0 Fiber (Nestle) Standard formula with fiber 1 cal/mL (isotonic); 1.2 cal/mL; 1.5 cal/mL Jevity contains soluble and insoluble fiber

22. Disease Specific Formulas Glucerna (Abbott) or Diabetisource (Nestle) For diabetes Fiber containing, low carb Nepro (Abbott) or Novasource Renal (Nestle) For renal disease Electrolyte and fluid restricted, 1.8cal/mL High in protein, low carb Nutri-Hep (Abbott): Liver failure with fulminate encephalopathy BCAA, Low in protein

23. Choosing an Enteral Formula Hemodynamic stability Is the patient in the ICU? Choose fiber free Previous diet tolerance Regular diet: trial polymeric formula Malabsorption: fiber free vs semi-elemental Special nutrient needs Low glycemic index Indication for immune modulators L-Arginine Omega-3’s

24. Choosing an Enteral Formula Electrolyte balance Does the pt need potassium and phosphorous restriction? Fluid needs Euvolemic? Volume overload? Hypo or hypernatremia? Elderly? Diarrhea/constipation?

25. Types of Feeding Administration Continuous feeding Controlled amount of formula delivered each hour by pump Intermittent feeding Delivered by gravity using a bag or syringe (bolus) For adult patients, usually 250-500mL can be delivered each feeding

26. Determining TF Goal Calculate energy and protein needs Determine strength of formula Example:1.2 kcal/mL Determine volume of TF required to meet needs Divide energy requirements by strength Decide on how TF will be infused and divide by frequency Example: bolus (TID) vs continuous (24h) vs cycle (16h) Calculate protein provided by TFs and use modular if indicated

27. Fluid Needs Estimate your patient’s fluid needs 30-35mL/kg 1 mL per kcal 1000mL x body surface area Calculate free water from TFs 1 kcal/mL: 84% water 1.2 kcal/mL: 82% water 1.5 kcal/mL: 76% water Volume of TFs x % water/100 Final calculation: Pt requirement – water from TF= amount to give as free water/IVF/flushes/bolus

28. Initiating & Advancing Feeding ASPEN guidelines Continuous feeding In stable adult patients, can initiate full strength formula at 10-40 mL/hr and advance 10-20 mL/hr every 4-8 hours until goal rate is achieved Different institutions have different guidelines Bolus feeding Initiate with 120mL bolus, advance by 60-120mL bolus every 8-12 hours as tolerated. Typical goal volume per bolus: 250-500mL Number of feedings/day depends on amount of formula needed to meet energy needs

29. Writing your Recommendation Formula name Initiation rate Advancement rate Goal rate Additional fluid needs

30. Monitoring Enteral Feeding Refeeding risk Electrolytes: K, PO4, Mg Trend Prealbumin, CRP Monitor blood sugars Monitor weight Monitor enteral infusion volume Appropriateness for cycling/bolus Skin integrity

31. GI complications Nausea and vomiting Increase risk of aspiration Abdominal distention Could indicate ileus, obstruction Constipation Look into hydration status, inadequate or excessive fiber

32. Diarrhea No universal definition for diarrhea Normal stool output is 250-500mL/day Investigate potential causes of diarrhea Infectious vs osmotic Check medication list for elixirs, sorbitols, po electrolyte repletion Check fiber provision Check osmolality Troubleshoot: change one thing at a time Adjust infusion rate Adjust fiber content Change formula Anti-diarrhea medication

33. Mechanical Complications Tube clogging Can be prevented with routine flushing of feeding tube Aspiration Symptoms include dyspnea, wheezing, anxiety, agitation Prevention is crucial. Should maintain head of bed at appropriate angle, greater than 30 degrees

34. Tube Feed Clog Myth : Coca-cola will unclog a feeding tube Fact : Cola products actually cause coagulation of proteins in the tube and can worsen the clog and in addition, deteriorate the integrity of the tube Use warm water to flush the tube Trial combination of enzymes and bicarb to dissolve clog

35. Question 3 Which of the following is the most appropriate initial action to diarrhea for a patient on TFs? A.D/C tube feeds and start TPN B.Review medications C.Change to elemental enteral formula D.Add pro-motility agent

36. Summary Enteral nutrition support is preferred over parenteral nutrition support Evaluate appropriateness of enteral feeding on a patient by patient basis Decide on appropriate feeding route access Choose best formula Monitor initiation and advancement carefully

37. Questions?

38. Case Studies

39. Case Study 1 70 yo F with PMH including HTN & DM admitted s/p stroke. She is awake and working with PT but has failed multiple SLP (speech & language pathologist) evaluations for an oral diet. SLP recommends NPO

40. Nutrition Care Plan What is your nutrition diagnosis? What is your plan? What route will you use to feed her?

41. SLP suspects long term impairment of swallow function. Which type of access would you suggest?

42. Her needs are estimated to be 1700 kcal/day Which formula and feeding regimen would you suggest?

43. She is unable to tolerate TF. She c/o bloating after feeds and has had multiple episodes of N/V associated with feedings. What is your Nutrition Diagnosis?

44. What can you do to improve tolerance?

45. She continues to have N/V and residuals persistently > 400mL. She has a gastric emptying study which confirms severe gastroparesis. Why do you think she has gastroparesis? What are you going to do?

46. Plan is to convert to PEG-J. What is your TF recommendation? (1700 kcal, 75g protein) What do you need to monitor when cycling? What else will you monitor for tolerance?

47. She would like to do bolus feeds. What is your recommendation? Why?

48. Case 2 28 yo F with no significant PMH who admits with abdominal pain and findings consistent with gallstone pancreatitis. Nutritionally, pt presents with 14 days of hypocaloric intake related to abdominal pain What is your nutrition diagnosis?

49. The team makes her NPO, but recognizes that she is malnourished. They consult nutrition to assess the best route for feeding. What do you recommend? Why?

50. The team places a NJT. What do you recommend for an enteral formula? You choose a formula with 1kcal/mL concentration & 50 g protein/L. What is the hourly TF infusion rate needed to meet her daily goals: 2100 kcal/day and 114 g protein/day? Does she need a protein modular (6g protein per scoop)?

51. Case 3 78 yo M with DM, HTN, CAD and ESRD on dialysis presents with failure to thrive. On examination by SLP, pt is considered at risk for aspiration and is made NPO. The plan is to place an NGT until swallowing function improves.

52. Which tube feed formula are you going to choose? Calorie goal is 1900kcal/day. What is the TF goal rate (concentration is 1.8kcal/mL)? What are you going to monitor?

53. Within 24 hours of initiating enteral nutrition, his K dropped to 2.7 mEq/L (3.4-5 mEq/L) and his PO4 dropped to 1.2 mg/dL (2.4-4.3 mg/dL). What are your choices?

54. Case 4 Your patient is getting Osmolite 1.2 at 70mL/hr, continuous (goal). When you review his labs 3 days after initiation of TFs you find that his serum Na has increased to 150 mEq/L (normal is 136- 145mEq/L). What should you do?

55. Solution: Choice A Estimate Calorie needs: Estimate fluid needs: TF provide: Difference is: Choice B Increase free water provided in TF Change to:

56. Questions?