1. Adult Enteral Nutrition Deciphering the Code Mark H. DeLegge, MD, FACG, AGAF, FASGE Digestive Disease Center Charleston, SC

2. Indications for EN “If the gut works…use it” EN is the preferred route of nutrition when oral intake is inadequate or a patient is unable to eat.

3. What Do We Infuse?

5. Formula Selection Assess digestive and absorptive capacity and GI tolerance Determine kcal, protein, fluid, vitamin and mineral requirements Determine if there are any mineral or electrolyte restrictions Assess indication for specialty formula Identify tube of type and infusion method

6. What’s the Situation 65 y/o F s/p CVA NG tube for feeding Weight: 60 kg Est kcal needs: 1500kcal/day (25 kcal/kg/day) Est protein needs: 60 gram/d (1 gm/kg) Normal gastrointestinal function No mineral or electrolyte restrictions –Renal disease

7. Tube Feeding Formulas *Blenderized (Table food) Standard isotonic (Most common) HN - High nitrogen Nutrient dense Fiber-containing Hydrolyzed Specialty

8. FormulaCal/ccProtein/L (gm) Free H20/L Standard1.0644842 Calorie Dense 2.084700 High Nitrogen 1.367837 Small Peptide 1.040 - 75850 Immune Enhancing 1.594759 Hydrolyzed 1.042867

9. In Our Patient Normal GI function No need for high protein diet No evidence of renal failure, uncontrolled diabetes No requirement of “high-tech” specialty formula 1500 kcal/24 hours = 60 cc/hr

10. Blenderized Product Essentially blenderized table food 1 calorie/cc 85.4% water Osmolality: 340 mosmo Lactose-free Moderately expensive  Compleat-B

11. Standard Enteral Products  Low residue  1 cal/cc  300 mOsmo  Lactose-free  Inexpensive, moderately palatable  Casein protein - biological value lower than other sources of protein

12. Nutrient Dense Formulas  Low residue  Functional GI tract required  Lactose-free  Inexpensive, moderately palatable  Casein protein  Fluid restricted patients  Renal compromised patients  Nutren 2.0, Magnacal, Jevity 1.5

13. High Nitrogen Products  Low residue  Functional GI tract required  Lactose-free  Inexpensive, moderately palatable  Casein protein, higher concentration  Patients with wound healing, post-surgical, trauma, sepsis  Example: Replete, Osmolite HN

14. Peptide-Based Formulas  Protein source: short peptides +/- free AAs  In times of stress small bowel mucosa ability to absorb short peptides increases  Altered GI tract absorption  Critical care  Inflammatory bowel disease  More expensive than standards  Example; Peptamen, Perative

15. Dipeptides, Tripeptides, Short Peptides Small intestine absorption (PepT1) Fasting: increase in small intestine (PepT1) and (PepT1MRNA) at the small bowel mucosa (peptides 6-100 in length) Inflammatory gut conditions – increase in small intestine (PepT1) production Ogihara et al; Histochem J, 1999

16. Elemental Formulas  Macronutrients in most elemental form  Protein: Free AAs  Fat: MCT, long-chain fats  CHO: glucose polymers  Expensive, unpalatable, High osmolality  Example: Crucial, Vital HN, Vivonex

17. Our Patient 1500 kcal, 60 gm protein, 1800 cc H 2 0 Standard: –1.5 liters (1500 kcal) –66 gm protein –1270 cc/H 2 0 Nutrient dense (2 cal/ cc) –750 cc –63 gm protein –462 cc H 2 0

18. Specialty Additives

19. Immune Enhancing Formula

20. Definition L-Arginine Glutamine Dietary Nucleotides N-3 Fatty Acids Immune Modulating Ingredients

21. Immune Modulating Nutrition: Meta-Analysis AuthorJournal# of PtsStudiesOutcome HeysAnn Surg 1999 100911Dec infection BealeCCM 1999148212Dec infection Dec vent HeylandJAMA 2001241922Dec infection Dec LOS WaitzbergWJS 2006 (in press) 230517Dec infection Dec LOS

22. Consensus Recommendations Appropriate Patient Populations Patients undergoing elective GI surgery: Greatest benefit in malnourished Trauma patients with ISS  18 or ATI  20 Needs further study Patients with severe sepsis Other patients that may benefit: –Ventilator dependent –Elective surgery (prolonged need for ventilator, cancer with malnutrition) –Severe head injury –Burns  30% (third degree) –Head and neck cancer

23. Metabolic Effects of Lipids Omega-3 series –Vasodilatory –Anti-inflammatory –Anti-aggregatory –Immunostimulant –Anti-arrhythmic Omega-6 series –Vasoconstrictive –Pro-inflammatory –Pro-aggregatory –Immunosuppressive –Pro-arrhythmic

24. Enteral Formulations Medium Chain Triglycerides Easier absorption Less pancreatic stimulation Less immune suppressing

25. Medium Chain Triglycerides 24 HIV + patients with malabsorptive disease LCT vs MCT enriched oral formulas 3 day 100 gm fat diet, then trial diet 3 days Craig et al; JADA, 1997 Gm/Day LCT

26. Types of Feeding Administration Continuous- given over 24 hours Bolus - syringe feedings given every few hours (e.g. 240cc every 4 hours) Nocturnal - TF given over 8-12 hours at night while patient is sleeping

27. Conclusion Know the code Assess GI tolerance Determine calorie, water, protein needs Evaluate co-morbidities Determine any special needs Determine infusion method Write the nutrition prescription