Uploaded byDr Riham Hazem Raafat
Enteral nutrition
The document discusses enteral nutrition in ICU patients, noting the prevalence of malnutrition and the critical need for nutritional support via enteral or parenteral feeding. It highlights the benefits, indications, contraindications, and complications associated with enteral feeding, alongside detailed protocols for tube placement and administration. The document emphasizes the importance of early nutritional intervention to improve patient outcomes and outlines considerations for different delivery methods and feeding regimens.
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Enteral nutrition
- 1. EnteralNutrition BY: DR. RIHAM HAZEMRAAFAT, MD
- 2. The Basics ofNutritional Support • Most patients in ICU are unable to tolerate normal diet • Many of them are malnourished on admission • Nutrients can be delivered directly to the GIT by feeding tubes (enteral feeding) or by intravenous (parenteral feeding) • Nutrition is provided against a background of a continuously changing physical status • Few data directly compare feeding with no feeding in critical patients and it suggests worse outcomes in underfed patients • Catabolism in critically ill patients causes malnutrition • Malnutrition closely associated with poor outcomes
- 3. • Stress, acuteillness, surgery or trauma produce major changes in the metabolic milieu of the body - Changes in substrate utilization - Altered substance synthesis rates - Hyper-metabolism - Catabolism
- 4. Why Malnutrition inCritically Ill Poor intake Stress Hyper- metabolism Changes in Substrate Utilization Surgery Immobility Prolonged Bed Rest Steroids
- 5. Consequences of Malnutrition •Increased morbidity and mortality • Prolonged length of stay in ICU • Impaired tissue function and wound healing • Defective muscle function, reduced respiratory and cardiac function • Immuno-suppression, increased risk of infection • Poor weaning from ventilator
- 8. Enteral Feeding Early feedingis usually defined as starting within the first 24-48 hours of admission – Goal is reaching 50-65% of caloric needs by the first week (Meta-analysis suggests reduced infections if patients are fed within 48 hours)
- 9. Indications for EnteralNutrition • Malnourished (unable to eat) >5-7 days • Normally nourished patient (unable to eat) >7-9 days • Increased needs that cannot be met through oral intake (e.g. burns, trauma, stress) • Adaptive phase of short bowel syndrome • Mental incapacitation • MV
- 11. Benefits of EnteralFeeding • Prevents gut mucosal atrophy by preserving intestinal mucosal structure and function • More physiological • Relatively non-invasive, cheaper, easier • It reduces bacterial translocation and multi-organ failure • Reduced risk of infectious complications of PN
- 12. Contraindications of EnteralNutrition Inability to gain access • Paralytic Ileus (relative) • Bowel Obstruction • Intestinal ischemia • Severe GI Bleeding • Vomiting / Diarrhea • High Output Proximal Fistula Clinical shock / Hemodynamic instability Expected need less than 5-7 days in malnourished or 7-9 days in normal
- 13. Enteral Access Delivery methodCommon indications Precautions Nasogastric/Orogastric (up to 4-6 weeks) (fine bore 5-8 FG or large bore) (polyurethane, rubber & silicone) - Unable to consume oral nutrition (Intubated, sedated, neurologically impaired) - Hypermetabolism in the presence of functional GIT (e.g. burns) - Tube must be secured - Verify placement of tube by ausc. or x- ray (gold) or PH or aspirate or cynography - Higher aspiration risk in large bore ‘e higher injury to nose/oes but ↓ clogging Nasoduodenal/Nasojejunal (up to 4-6 weeks) (fine bore 6-10 FG) 1F = 1/3 mm so 12F = 4mm -Inadequate gastric motility or intolerance (gastroparesis, delayed gastric emptying) - Partial gastric outlet obstruction - Severe aspiration risk - Oesophageal reflex - Coma lying flat - After upper GI surgery - In high GRV - Tube must be secured - Verify placement of tube by X-ray (fluoroscopy) or endoscopically - Bedside is difficult and failure rate is 70- 85% Gastrostomy (silicone or PU) -PEG (pull, push, introducer, mini laparoscopically guided) -Radiological -Surgical -Anyone who requires medium to long term NG tube feeding ( > 1 month) -Head and neck injury/surgery -Neoplasm in UAWs or Oesophagus - Caution in patients with severe GERD or gastroparesis – Abs (6hr before) - Contraindicated in patients with ascites, coagulopathies, die <3M, Jejunostomy (solid > balloon) -PEJ -Surgical *Both G & J: 2 or 3 ports - Injury, obstruction or fistula proximal to jejunum peritonitis, morbidly obese - Monitor bleeding, not removed 14 ds, early feeding (2hrs adults, 6hrs children)
- 17. Contraindications to NGand NJ intubation: – Obstruction of the nasopharynx and esophagus, – Recent foregut surgery that may predispose to perforation – Craniofacial fractures. Contraindications of PEG: – Intolerance to pre pyloric feeds, abdominal pain with feeding, and repeated regurgitation of the feeding solution Relative contraindications to NG tube placement: include – Severe gastroesophageal reflux, – Coagulopathy, and – Esophageal variceal bleeding.
- 18. Complications of EnteralNutrition Reactions Possible Causes Diarrhea +/- Nausea and Vomiting Dehydration Infection Medications/C. difficile/lack of dietary fiber/hyperosmolar formula/bacterial contamination/improper administration/fat malabsorption Constipation Inadequate fluid intake/insufficient fiber/GI obstruction Aspiration of tube feeding/high gastric residuals (>250 in 2 or 500 in 1) Regurgitation of stomach contents/feeding while supine/delayed gastric emptying/tube dislodgement/GERD Hypoglycemia Sudden cessation of tube feeding in patients on oral HG/insulin Hyperglycemia Diabetes/stress/trauma/corticosteroid/sepsis/refeeding $ Hypophosphatemia / Hypokalemia Refeeding syndrome / excessive losses Others due to technique itself or after tube insertion (minor 13% or major 3%) GERD/aspiration/wound infection/bleeding/misplacement: pnthx/ epistaxis/ pneumoperitoneum/fistula/neoplastic seeding/infection/mortality (1%) Clogging/sinusitis/intestinal ischemia (if hemodyn unstable EN)/dislodgment/malfunction/peristomal infection/leak/BPS
- 19. If Starvation for7-10ds: Arrhythmia, HF, RF you have to correct imbalance before NS
- 20. Methods of Administration ContinuousIntermittent Bolus Use - Intubated. - Jejunostomy. - Critically ill. - Glycemic index control - Refeeding. - Intolerance to intermittent. *↑ time of absorption - In stomach. - ↑ fluid tolerance. - During day or sleeping hrs by using alarm. - ↑aspiration - Better ↑ in day & ↓ in night→ ↑ QOL (in rehab & home) - Needs N gastric function I. Bags → clamp. II. Syringe & Funnel→ raise & down or pressure. - Mimic normal eating. - ↓cost - ↑ aspiration, distension, delay GE - ↑movement of patient Rate 20-60ml/hr & advance by 10-20ml/hr/8- 24hrs 240-400ml (begin 60-120ml) (1-3 cups) in → 30-45mins→ 4-6 times daily (flush) Gravity drip. 150-500ml/ 5-15mins/ 3-6 times.
- 25. Broad Lines • Choosefull strength, isotonic formulas for initial feeding regimen. • Diluting formulas may increase the risk of microbial contamination intolerance due to diarrhea • Gastric Feeding and Stable Patients: – Initiate with full strength formula: 50 ml/hr X 3-8 times bolus/gravity method. – Increase up to 50-100ml/hr every 10-12 hrs till goal volume (usually 24-48hrs) • Small-bowel feedings & Gastric feedings in critically ill patients or severely malnourished patients: – A pump is generally required as the slower administration rate of continuous feedings often enhances tolerance. – Start as full strength (iso/hyperosmolar/elemental): 10-40ml/hr 3-8 feeds, if tolerates well increase by 10-20ml/hr every 10-12 hrs till goal reached.
- 26. • Elevate thebackrest to a minimum of 30º, and preferably to 45º, for all patients receiving EN unless a medical contraindication exists. Chlorhexidine mouth wash twice daily. • If patient can’t tolerate high rates feeding rate decreased till he adapts. • If the GRV (amount of formula and GI secretions remaining) is > 250 mL x2 times a prokinetic agent should be considered in adult patients (erythromycin / metoclopramide) • If the GRV > 500 mL/6hr hold EN and reassess patient’s tolerance by using an established algorithm including: physical assessment, GI assessment, evaluation of glycemic control, minimization of sedation, and consideration of promotility (prokinetic) agent use if not already prescribed. • Consideration of a feeding tube placed below the ligament of Treitz when GRVs are consistently measured at > 500 mL
- 27. Catheter Care: - SkinCare: water and soap is the best, avoid pressure, oral hygiene - Clogging Prevention: 1. Flushing protocol: Flush with water 30-60ml (flush of choice) or pancreatic enzymes. 2. Medications: Administered separately, Flush before and after, Use liquid medications. - Exchange and Removal: not before 2 weeks (or 4-6 weeks in IS, CS, Obese) for G or J tubes 1- Removal at bed side with traction method: Patient lies supine and bend his knees (For solid bolsters → tube grasped by force and For balloon bolsters → balloon inflated and removed) 2- We better use surgical lubricant.
- 28. • Flush feedingtubes with: – 30 mL of water every 4 hours during continuous feeding. – Before and after bolus/intermittent feedings in an adult patient. – After measuring GRV (measured every 4 hrs till goal reached and in critically ill patients (decrease measuring to every 6-8 hrs if patient is stable) • Sterile water is usually recommended, for flushing and mixing medications (contribute to fluid intake) • Precautions in flushing: Orange Juice Damages PU tubes. Papain and NaHCO3 Damages PU & silicone tubes. H2O + pineapple juice Can be used. ↑ intact protein + Acidic medications ↑ clogging so not use soda or cranberry juice for flush.
- 29. Formulations Formula Composition: (1-2kcal/ml) 1.Carbohydrates (30-60% of Cal) 2. Fibers (+/-) 3. Fats (15-30% of Calories) 4. Proteins (15-25% of Calories) 5. Vitamins and Minerals (RDA) 6. Water (70-85% of Volume – 30-40ml/kg/d) 7. Osmolality (270-700 mOsm/kg) (iso/hyper) 8. Immuno-modulating Agents (arginine/glutamine/omega 3 …etc.) Types of Formulas: • Standard (polymeric) • Disease specific • Elemental or defined (mono/oligomeric) • Home made • Modular (only one) Don’t Mix drugs or additives with enteral formulas flush before & after
- 30. Formula Selection Dependson: – Patient’s Condition (age / allergies / tolerances / diseases) – GI status – Need of Fiber Modifications – Enteral Route (gastric vs small bowel) – Nutritional and Fluid Requirements
- 31. 1.2 up to2 gm/kg/d in critically ill
- 33. Open System Closedsystem Advantages Product is into: powder or ready to fed - Allows modulars such as protein and fiber to be added to feeding formulas - Less waste in unstable patients (maybe) - Containers are sterile until spiked for hanging (ready to hang 1L, 1.5L, 2L) - Can be used for continuous or bolus delivery - Less waste of formula - Less nursing time - Increases safe hang time (24-48hr) - Less risk of contamination Disadvantages - Increase nursing time - Increase risk of contamination - - Shortens hang time (4-8 hrs) - - Rinsing of bag and tubing - No flexibility in formula additives (can use Y port for additions) - More Expensive than open formula
- 34.
- 35. EN Safety We shouldhandle EN in a safe manner to avoid contamination in all aspects of care e.g. preparation, manufacturing, infusion. • Contamination: Precautions to avoid contamination: - Use gloves, hand washing. - Pump Cleaned daily. - Cans with alcohol, - Container sanitized and labeled with name & time. • Sanitization - Changed every 24 hrs. - Use screw top connectors not flip top. - Use spike set. - Connections differ than IV lines are better - Infusion chambers→↓ retrograde bacteria. • EN set (different hang times) - Closed system - Open system → Refrigerated if not adm. immediate & the remaining is discarded
- 37. Transitional Feeding - Fromcontinuous → intermittent → oral. - Stop EN if oral intake → 66-75% (2/3) of total calories. - Monitor tolerance (↓ duration, ↑ volume)
- 38. Videos that mayhelp: • https://www.youtube.com/watch?v=2MPM9XvadQo • https://www.youtube.com/watch?v=_EDUAVTHQtk&index=2&list=FLa_kHXFy UdiFBuZLLkzLMXg&t=24s • https://www.youtube.com/watch?v=yRmRMHfG7g0&index=1&list=FLa_kHXFy UdiFBuZLLkzLMXg • https://www.youtube.com/watch?v=lpxdUFVOibk