Download Early Enteral Feeding

Enteral Nutrition (EN)
A meta-analysis attests to the feasibility of early postoperative EN in high-risk surgical patients and that
these patients have reduced septic morbidity rates compared with those administered PN.”{Moore et al.,
1992, #79138}
Patient Case
• 65-year-old male admitted for respiratory failure 13 days ago.
• PMH: HTN, CAD, COPD, CRF with dialysis MWF
• Hypotensive event after admission, now on low dose dopamine
• Ventilated on sedation protocol (fentanyl/lorazepam)
• TF started 4 days ago. Held for residuals of 150 ml.
• Metoclopramide initiated 5 mg IV Q6h
Last BM prior to arrival, and Bowel Sounds Minimal
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• Abnormal Labs K-5.2, Cl 116 , CO2-21, BUN-63, Cr-7.9, Alb-2 3, Phos-6.6 MAP 68, no boluses
• Anthropometrics include: Ht 73 inches, Wt 79 kg, BMI 23 kg/m2
Pharmacist is asked to evaluate patient for TPN
Indications for Enteral Nutrition (EN)
Estimated time to oral intake. (NOT waiting for this endpoint, but upfront evaluating when to start EN)
• Well nourished 10 – 14 days
• ICU > 5 days
• Poorly nourished non ICU ?
Pts with adequately functional GI tract whose oral calorie/nutrient intake is insufficient to meet needs
• Poor appetite, Hypermetabolism, Neurological disease/injury, GI disease, Oncologic disease, Psychiatric
disorders, and Organ failure
Contraindications to Enteral Nutrition
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Inability to access the GI tract
Insufficient absorptive capacity
Obstruction of GI tract
Prolonged ileus
Severe GI hemorrhage
Severe diarrhea
Intractable vomiting
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High output fistula (proximal versus distal)
Abdominal trauma
Bowel ischemia
Severe Pancreatitis
Terminal illness
Feeding the Hypotensive Patient
• Hypotensive patients are probably NOT good candidates for EN, because of issues with oxygen
competition resulting in ischemic gut which can result in a catastrophic complication.
• MAP < 60 mm/hg
• Bolus IV fluid requirements b/c of hypotension
• Increasing doses of pressor agents
• Addition of multiple pressors
Enteral Feeding Myths
• No Bowel Sounds
• Lack of bowel sounds does not preclude or contraindicate safe enteral nutrition (EN)
• Other parts of the gastrointestinal tract may be working. This can happen where we have a gastric
ileus causing the stomach not work appropriately.
• Patients without bowel sounds can be fed safely with EN
• Enteral Feeding causes diarrhea
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Most often it is NOT the enteral feeding, but exacerbating factors and medications that cause
diarrhea. Hyperosmolar liquid formulations (elixirs), sorbitol content, antibiotics (killing normal
flora), bacterial overgrowth, impaction, malabsorption, lack of fiber
Aspiration risk
• Two feedings can be aspirated. The question is the EN the cause of aspiration? NO
• In this situation we need to be vigilant, but not panicky about aspiration
Oropharangeal secretions aspiration versus EN contents
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• EN may actually decrease risk of aspiration
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Enteral Feeding Advantages
• Physiologic feeding – as opposed to intravenous nutrition
• Metabolic – feeding into the intestinal tract allows the body to respond more normally causing
significantly fewer metabolic complications
• Immunologic – Enteral feeding allows the body to process foods in a more normal manner stimulating
immune function.
• Safety – Enteral tubes are much safer than a central line.
• Cheaper
Attenuation of Hepatic Protein Reprioritization{Peterson et al., 1988, #75631}
• Peterson, et al, 1988. They discovered this by measuring positive acute phase reactants to alpha
antichymotrypsin which showed enteral feeding decreased the liver’s production of this protein which is
used to describe metabolic stress response
★ Results: early enteral feeding showed decrease STRESS response
Intestinal Immunology
Mucosal (barrier functions)
• Gastric acidity – Kills bacteria
• Normal bowel flora – Blocks absorption of
toxins and unwanted bacteria
• Intraluminal proteases – Break down toxins
• Peristalsis – Moves toxins through the GI tract
• Globular cell mucus
• Normal enterocyte membrane composition
GALT (gut associated lymphoid tissue)
• Peyers patches
• Antigen presenting cells and lymphocytes (lamina
propria)
• Intraepithelial lymphocytes
• Mesenteric lymph nodes
• 1010 Ig producing cells/Meter small bowel (70%)
• 10gms sIgA daily
Immunologic Gut-associated lymphoid Tissue (GALT)
• 25% of intestinal mucosa is lymphoid
• 70 – 80% of ALL immunologic secreting cells in the body are associated with the GI tract
• Largest immune organ in the body
• Supplies immune function for the OTHER mucosal organs, (e.g.) Genitourinary tract, pulmonary, and
the gastrointestinal tract.
Factors affecting the GALT
• What could affect the secretion of IgA & sIgA?
• Decreased fuel if not feeding into the gut.
• Decreased fuel GI stimulation (Hypoplasia seen as decreased villi height)
Bacterial Translocation
Bacterial translocation is the movement of bacteria and endotoxins through the lining of the intestinal tract
in a way that it overloads the lymph system, AND the reticular endothelial system leaving us with what is
referred to as gut derived sepsis.
• Bacteria or endotoxins
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Normal occurrence
Normally handled by the reticuloendothelial system
Increased when barrier defenses damaged
Increased when GALT function is affected, because we get lower amounts of sIgA.
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Healthy GI Tract with a good mucosal protective layer. Here you have adequate protective flora
protecting the endothelial cells from bacteria that may adhere to them and be translocated.
NOT adequately feeding the gastrointestinal tract. There is breakdown of the mucoid layer, and loss
of the friendly flora. This results in bacterial translocation.
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8 healthy parenteral nutrition (PN) for 2 weeks, and THEN a second biopsy showed results{Buchman et
al., 1995, #52694}
• The results where that the volunteers lost 50% of their villi height in that short amount of time.
★ This is due from not stimulating the gastrointestinal tract with enteral nutrients.
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Enteral Feeding Disadvantages
• Disadvantages of enteral feeding include the outcome of having a patient who has a decubitus ulcer or
other types of wounds that could be soiled by POOP! Colostomy have been placed to allow for healing
of these ulcers.
• Another disadvantage gut ischemia (caused by hypotension)
Some of the indirect complications include aspiration that results from poor motility, and subsequent
vomiting
• Indirect (complications)
• Aspiration → ileus or vomiting
• Infection, injury, or leakage from tubes or tube sites
• Diarrhea → toxins, sterile gut, slick gut, over treatment of constipation, or osmotic agents
Feeding Locations
Insertion site
• Nasal
• Oral
• Abdominal
Feeding location
• Gastric
• Duodenal
• Jejunal
Types of tubes
• Nasogastric tube, Nasojejunal tube, percutaneous endoscopic gastrostomy tube (PEG Tube),
Laparoscopic placed jejunostomy tube, Percutaneous endoscopic gastrojejunostomy, gastroduodenal
tube.
Gastric Placement Advantages
• Decreased stress bleeding
• Less diarrhea
• Ease of access
• Lower cost
Transpyloric Advantages
• Bypass gastric ileus or obstruction
• Decreased risk of aspiration
• Less stimulation of the biliary tree
• Don’t have to check residuals
Enteral Administration
When do we start the process of enteral administration? EARLY
• Sooner? (or later?), 6 hours post admit?, 24 hours post admit?, 72 hours post admit?, Next year?,
Nutritional Risk?, Hemodynamics?
• Good data shows burn patients should start 6 hours after INJURY
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Timing
• Early is better
Early Enteral Feeding
• ASPEN (American)
• Enteral feeding should be started within the first 48 hours after admission
• Feedings should be advanced to goal over the next 48-72 hours
• ESPEN (European)
• All patients not EXPECTED to have full oral intake within 3 days should receive enteral nutrition
• Expert committee recommends feeding the hemodynamically stable ICU patient within 24 hours
Caloric Deficit “a Debt That Must Be Paid”
• Clinical nutrition week in 2010 – Caloric Deficit > 10,000 kcal = 86% death.
Early Enteral Feeding
• Within 48 hours – here we may not get to goal, but 25% of goal rate will stimulate immune function
within the gut.
• Trophic rates
• Helps maintain immune function
• Decreases acute phase response
• May improve tolerance to enteral feeding
• Non-ICU patients – May not have to be as aggressive but again sooner is better than later
How do we implement this enteral feeding?
• Continuous gravity feedings
• Intermittent gravity feedings
• Bolus with a syringe
• Pump controlled either all day or night feedings OR Cycled
Goal Rates
How fast we run enteral feeding?
• Not everyone gets100ml/hour
• Here we consider types of tube feeding, nutritional needs, and caloric assessment
• Each patient needs to be individualized both with their feeding, rate, and amount.
• Check goal assessment and compare to kcal/ml
• Always start at FULL strength. There is NO advantage to half strength
• Start at 25% of goal (roughly 25 to 30 mL per hour)
• Advance 10-20 mL Q4-6 hrs as tolerated to goal rate (~48 hrs)
• Not everyone will tolerate rapid advances
• Be careful when turning off or on feedings
• When turning feedings off we need to make sure that they are then turned back ON soon.
Monitoring Tolerance of Enteral Feedings
• Vomiting – Which could cause us to stop EF
• Lactose intolerance – most of the enteral feedings are lactose FREE
• Gastric ileus – This concerns us when our gastric residual volumes (GRV) are > 800 mL – 1000 mL
• Having a gastric ileus could lead to Aspiration
• Abdominal distention
• Diarrhea – treat and understand causes in the process of enteral feeding.
• Constipation
Aspiration
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Aspiration – Inhalation of material into the airway below the level of the vocal cords “stuff in your
lungs”
Leading cause of pneumonia in the ICU
Most serious side effect of enteral feeding
Risk may decreased by effective enteral feeding
Major Risk factors for Aspiration
• Documented previous episode of aspiration
• Decreased level of consciousness which leads to the inability to swallow
• Endotracheal intubation
• Vomiting
• Persistently high gastric residuals
• Need for prolonged supine position (lying flat)
★ Have the bed with at least 30° incline
Methods of Aspiration Monitoring
• Glucose oxidation monitoring – shown not to be effective in monitoring for aspiration
• Blue dye coloring
• Gastric residual volumes
• Most effective are: Video fluoroscopy, endoscopic laryngoscopy, Scintigraphy BUT all are difficult
within a hospital setting
Blue Dye Coloring - 49
• FD&C Blue #1 & Methylene blue
• Issues
• Amounts not standard, Risk of Contamination (serious and immunocompromised patients), and
Breaking sterile product
Warning against using BLUE coloring by FDA
• 20 reported cases due to this blue intestine, 12 deaths (hypotension and metabolic acidosis), Septic
patients with increased gut permeability
• FD&C #1 is a poison to Mitochondrial
• “Other blue dyes, such as methylene blue and FD&C Blue No. 2, may have similar if not greater toxicity
potential than Blue 1 and would not be appropriate replacements.”
• “This practice should be abandoned” Consensus statement 2003 (FDA public health advisory)
Gastric Residual Volumes (GRV)
• Poorly standardized
• Correlate poorly with gastric emptying
• Correlate poorly with volume of gastric contents
• Correlate poorly with volume of enteral feeding
• Correlate poorly with regurgitation
• DOES impede provision of nutrition
Gastric Residual Recommendations
★ If the gastric residual volume GRV is > 500 ml withhold feeding and reassess tolerance.
• GRV < 500 ml should be returned to the patient with continued monitoring.
• GRV 200 ml –500 ml do not confirm tolerance and should initiate activities to reduce risk.
• GRV < 200 ml seem to be well tolerated but evaluation should continue.
How to Improve Tolerance
• Prokinetic agents
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Increase the Head of Bed
Log roll to help with gastric emptying
Bowel Programs especially with patients on high dose Opiates
Increase concentration by using a 2 calorie per milliliter formulation rather than a 1 cal per milliliter
which decreases the amount of volume presented to the stomach.
Prokinetic agents
• Metaclopramide, Cisapride, Erythromycin (~200mg q12hrs), Choline/dexpanethol. Domperidone,
Tegaserod, Methylnaltrexone, Alvimopan, Sildenafil
• Metoclopramide and erythromycin are the two most common in the United States.
• Cisapride is available in other countries, and is available in the United States in a restricted manner
• Methylnaltrexone and Alvimopan are newer opioid antagonist agents.
Mechanical Complications
• Tube malposition – Perforation & Pneumonia (Tubes inadvertently placed in the lungs causing
pneumonia)
• Tube clogging – Feeding can clog the tubes (FLUSH!)
• Enzymes can break down this clog that has developed
• Mechanical means with different types of brushes that breaks up the clot
• Crushed medication causes many issues with clogging tubes
• Mechanical means is the only way to clear medication blockage
Monitoring Effectiveness of Enteral feeding
• UUN - Urine urea nitrogen (24-hour nitrogen balance)
• Metabolic carts
• Prealbumin & C reactive proteins (CPR)
• Electrolytes
• Hydration status – Free H2O additions is recommended for dehydrated patients
Alternatives to Continuous Feeding
Cycling
• Some patients may be eating, but just not enough yet. In this case we can infuse their tube feedings at
night allowing them to improve their oral intake.
• Total needs OR 50-60% of needs, may give for 12 hours during the night
Bolus feeding – infusing 200mL to 500mL at one time during meal times
• More physiologic, A better process for Rehab patients
Allows for mobility so the patient can move around
ISSUES with Enteral Feeding and Medication
Binding
• Ciprofloxacin & Phenytoin (dilute ?)
Crushing medications
• Everyone should have a list of medications that CANNOT be crushed available
• Certainly not any sustained release
• Liquids where possible – Be aware of Alcohol and Sorbitol concentrations.
Delivery site – Don’t deliver gastric absorbed drug it into the small intestine.
Enteral Formulas
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Standard Polymeric
Fibersource HN, Jevity, Nutren, Ensure, Boost
• 1 - 1.2 kcal/cc
• Whole proteins 35 - 45 gm/1000 kcals
• Most with Fiber
• Moderate nitrogen
• Some can be taken orally
• May not be beneficial in highly catabolic patient
patient
• Not recommended to be used with tubes
High Nitrogen
Isosource VHN, Promote, Replete, Traumacal
• 1.0 kcals/cc
• Whole proteins 60 gm/1000 kcals
• Fiber
• These of the formulas used in trauma units, burn
units, or any patient that are severely catabolic or
protein loosing for various reasons.
Moderately Low Volume
Isosource 1.5, Nutren 1.5
• 1.5 kcals/cc
• Fiber
• Moderate protein
• Used in patients that may require fluid
restriction, or not tolerating excessive amounts
of volume because of a 1 calorie per milliliter
formula.
Low Volume Polymeric
Novasource 2.0, Deliver 2.0, Twocal, Nutren 2.0
• 2.0 kcals/cc
• No fiber
• Moderate protein
• Used in patients that require fluid restriction (e.g
CHF)
• Used in patients that have a high volume
intolerance.
• These formulations can be administered at a lower
rate, and give the same amount of protein and
calories.
Elemental Formulas
Vivonex Plus, Vivonex HN, Vivonex TEN, Vital
HN, Tolerex
• 1 kcal/cc
• Free Amino acids are the protein source
• No fiber
• Moderate protein
• These formulas or for patients who show
intolerance to whole proteins.
• They may decrease diarrhea in patients that are
whole protein intolerant.
Semi-elemental Formulas
Peptamen, Subdue
• 1 kcal/cc
• Shorter chain peptides which are easily absorbed
without an energy requirement to break down for
absorption
• They are not truly free amino acids
• No fiber
• Moderate protein
• Increased MCT as fat component which are easily
absorbed
• These formulas are used in patients where you
have questionable ability for absorption (fistula)
Enteral Formulas
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Renal Formulas
NovaSource Renal, Nepro, NutriRenal
• 2 kcals/cc
• Whole proteins
• No fiber
• Average protein
• Lower fluid, and lower electrolytes (K, Mag, Phos)
which are needed in renal failure patients
• These formulas or for renal failure patients WITH
dialysis.
• These patients have a fluid restriction, but need
adequate proteins (aggressive proteins)
Hepatic Formulas
NutraHep, HepaticAid
• 1.5 kcal/cc
• Increased branched chain amino acids –
37gm/1000 kcals
• No fiber
• Lower protein
• Low sodium
• Minimal amounts of ammonia are released
with these formulas.
• These formulas are mainly used with patients
who are comatose with encephalopathy.
Very Low Protein Formulas
Suplena, Renalcal
• 2 kcals/cc
• Whole proteins
• No fiber
• These formulas or for patients who TRULY need
protein restriction. This primarily includes patients
who are with renal failure, but are not yet
undergoing dialysis
Diabetic Formulas
Diabetasource AC, Glucerna, Glytrol
• 1 - 1.2 kcal/cc
• Whole proteins
• Fiber
• Moderate protein
• Decreased carbohydrate and increased fat
• Exposing a patient to lower carbohydrates will
give better glucose control.
Pulmonary Formulas
Novasource Pulmonary, Pulmocare, Respalor,
Nutrivent
• 1.5 kcal/cc
• Whole proteins
• No fiber
• Moderate protein
• Increased fat and decreased carbohydrate
• Same as diabetic formulas
• Pulmonary patients are retainers of carbon
dioxide.
Immune Enhancing Formulas
Crucial, Impact, Pivot
• Glutamine
• Arginine
• Antioxidants
• Increased levels of omega-3 fatty acids
• Reduced Omega 6 fatty acids
• Nucleotides
• These formulations attempt to minimize the
stress response & sepsis
Oxepa
• 1.5 kcal/cc
• Whole proteins 42 gm/1000 kcals
• No fiber
• Average protein
• 45-55% total kcals lipid
• Oxepa specific indication for adult respiratory
distress syndrome (ARDS) lowers inflammation
Food Based Formula
Compleat
• 1.07 kcal/ml
• Whole proteins 40gm/1000 kcals
• Fiber
• 30% fat
• Moderate protein
• This is a food-based formula
Modular Additions
Modular additions to our tube feeding can be added. This includes extra protein, extra glucose, extra fat,
MCT oil, all of which help us modify the diet in ratios that are not of standard formulas.
• Additions to TFs – ProMod, Casec, Moducal, Polycose, MCT oil, Microlipid
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Patient Case
Issues
• Waited 10 days to start EN. We waited TOO long to start enteral nutrition.
• Hypotensive event now stable
• Residual cutoff too low (150ml) → Cutoff should have been at a MINIMUM of 200 mL
• Constipation with continuous fentanyl → needs bowel program
• Dialysis with high K and phos → needs renal formula
• Caloric deficit too high → needs nutrition NOW probably need to start PN until enteral tolerated
Take Home Message
• Enteral nutrition better then Parenteral nutrition
• Early enteral better
• Start at 25% of goal
• Advance over 48-72 hours
• HOB > 30 degrees
• GRV every 4 hours (200)
• Bowel program started early on especially with patients on narcotics
• Prokinetics
• NO BLUE DYE
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