Enteral nutrition methods Dr dharma poonia Rajiv Gandhi Cancer institute, new delhi

1. Enteral feeding methods
Dr Dharma
Rajiv gandhi cancer institute, Delhi.

2. CONTENT
• Introduction
• Access methods
• Administration.
• Complications
• summary

3. INTRODUCTION
• “Dietary foods for special medical
purposes’’
• independent of the route of
application.
• It includes
– oral nutritional supplements
– tube feeding
» the European legal
regulation of the
commission directive 1999

4. EPIDEMIOLOGY
• Approximately 5% of apparently ‘‘healthy’’ UK adults
were shown to have a body mass index (BMI) ,20
m/kg2.
• This increased to 10% or more for the chronically sick
and patients with cancer, gastrointestinal disease,
respiratory problems, and neurological or psychiatric
conditions

5. Advantages - Enteral vs PN
• Preserves gut integrity
• Possibly decreases bacterial translocation
• Preserves immunological function of gut
• Fewer infectious complications
• Safer &cost effective
• EN is only likely to benefit nutritionally depleted patients
or those at risk of becoming depleted.
ASPEN. The science and practice of nutrition
support. A case-based core curriculum.
2001; 147

6. Indications for Enteral Nutrition
• Malnourished (unable to eat) >5-7 days
• Normally nourished patient (unable to eat)>7-9 days
• Adaptive phase of short bowel syndrome
• Increased needs that cannot be met through oral intake
(e.g.,burns, trauma)
ASPEN. The science and practice of
nutrition support. A case-Based Core curriculum.
2001; 143

7. Contraindications for EN
• Inability to gain access
• hemodynamic instability
• High output proximal fistula, Intractable vomiting or
diarrhea, paralytic ileus, Intestinal obstruction,
Severe G.I. Bleed.
• Expected need less than 5-7 days if malnourished or
7-9 days if normally nourished.

8. ACCESS TECHNIQUES
• Up to 4–6 weeks
– NG or NJ tubes,
• Beyond 4-6 week with life expectancy more than
3months
– percutaneous gastrostomy or jejunostomy

9. ACCESS TECHNIQUES

11. Naso gastric (NG) feeding
Indications:
• Short term feedings required
• Intact gag reflex
• Gastric function not compromised
• Low risk for aspiration

12. Naso gastric (NG) feeding
• Fine bore 5–8 French NG tubes are now used
• Large bore PVC tubes  they irritate the nose and
oesophagus and increase the risks of gastric reflux
and aspiration.
• Polyurethane and silicone tubes
• Position of tube tip..

13. Naso gastric (NG) feeding
Advantages
•NG tubes can be inserted
bedside.
•It allow the use of
hypertonic feeds,
higher feeding rates, and
bolus feeding.
•Better tolerated.
•Easy to check gastric
residuals
Disadvantages:
• Increases risk of
aspiration (maybe).
• Not suitable for
patients with
compromised gastric
function
• May promote nasal
necrosis and
esophagitis
• Impacts patient quality
of life.

14. Naso jejunal tubes
• Jejunal feeding may be indicated if there are
– problems with gastric reflux or delayed gastric
emptying.
– It should also be used in unconscious patients
who have to be nursed flat.
– In patients who have more than 250-500ml GRV
or formula reflux in two consecutive measures.
• Fine bore (6–10 French gauge).

15. …cont
…cont
• Post pyloric placement can be difficult and various
techniques are used.
• Even in experienced hands, bedside placement of
nasojejunal (NJ) tubes is difficult and has a low
success rate of 15% to 30%.

16. ..cont
• Hence endoscopic placement is indicated in most
instances.
• Direct visualization methods
• Direct manipulation
• Through the scope (TTS)

17. • PRCT by Heyland et al demonstrated that
– Trend toward higher frequency of pulmonary aspiration in
intragastric feeding compared to postpyloric feeding (7.5%
vs. 3.9%) statistical nonsignficant.
– statistically signficantly higher gastroesophageal relux
between gastric feeding and postpyloric feeding (39.8% vs.
24.9%, P = 0.04).

18. NG vs NJ.
• Recent meta analysis did not show any difference
regarding mortality/ ICU stay between either
method.
• Recent ASPEN guidelines suggest only indication for
NJ tube is Gastric intolerance.
» Heyland, Ho KM and Marik et al

19. • Contraindications to NG and NJ intubation include
– obstruction of the nasopharynx and esophagus,
– Recent foregut surgery that may predispose to
perforation
– craniofacial fractures.
– 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 relux,
– coagulopathy, and
– esophageal variceal bleeding.

20. Feeding enterostomies
• Gastrostomy
– Surgically placed
• STAMM open / lap
• JANEWAY open / lap
– Endoscopically
• PEG
– Radiologically
• RPG
• Jejunostomy.
• Needle
• witzel
• Other methods
– Percutaneous gastrojejunostomy
– Percutaneous transesophageal gastrostomy tube
– Mini-laparoscopically guided percutaneous gastrostomy
– The segmentaion-based lossless image coded (slic) technique
– Direct percutaneous endoscopic jejunostomy
– Magnetically guided feeding tubes

21. Indications of enterostomies
• Who require long-term (>30 days) access to the GI
tract.
• They most commonly provide enteral nutrition in
those with
– Impaired swallowing/ cognition from neurologic
conditions
– Neoplastic diseases of the oropharynx, larynx,
and esophagus.

22. Contraindications of enterostomies.
– life expectancy less than 3months
– uncorrectable coagulopathy,
– peritonitis
• Cautions warrented in
– massive ascites,
– the morbidly obese,
– distended loops of small bowel,

23. STAMM GASTROSTOMY
– Egeberg in 1837
– Sellidot in 1849
Was gold standard before advent of PEG.
Laparoscopic SG Less invasive than traditional open
gastrostomy but more invasive than PEG tubes, it is
currently recommended for patients who require long-
term feeding access but who are not candidates for
endoscopic placement.

24. JANEWAY GASTROSTOMY
• Used when there is risk of inadvertent removal of
the gastrostomy, as in a confused and
uncooperative patient
Laparoscopic Janeway Gastrostomy

25. PEG
• In 1980 a percutaneous endoscopic gastrostomy
(PEG) technique was developed by Ponsky and
Gauderer as an alternative method to obtain gastric
access.

26. • Antibiotics 6 hrs
prior to procedure.
• Requires only LA

28. Push Technique (Sacks-Vine)
• This is similar to the pull method except that the PEG
tube is pushed over the taut guidewire.

29. Introducer (Russell) Technique
• It uses Seldinger technique for the placement of a
balloon-tipped PEG tube directly into the stomach,
using direct endoscopic Visualization.

31. POST -OP
• Not fed through PEG tube in the first 12-24 hours
after its placement. However recent evidence
suggest early innitiation of feeding.
• vital signs monitored-bleeding and leakage at the
PEG site.
• PEG should not be removed for at least 14 days after
insertion to ensure that a fibrous tract is established
that will prevent intra peritoneal leakage.

32. • The pull, push, and introducer techniques have all
been found to be effective and safe methods
• A well-trained Gatroenterologist should be familiar
with all three standard methods and be able to select
which one best suits a patient’s needs.

33. • Overall incidence of 10% to
16% based on large cumulative
retrospective studies.
– Mortality is 1%,
– major complication rate of
3%
– minor complication rate of
13%.
• Wound infection
• Buried bumper syndrome
• Leakage of feedings into
the peritoneal cavity
• Gastrocolic fistula
• Pneumoperitoneum(0.3%
• Neoplastic seeding
• Aspiration with
subsequent pneumonitis
Larson D, Burton D, Schroeder K: Percutaneous endoscopic gastrostomy:
Indications, success, complications and mortality in 315
consecutive patients. Gastroenterology 93:48, 1987

34. Radiologically Placed Gastrostomy
• They use Seldinger technique as described for the
introducer method.
• Common indications
– esophageal stenosis from malignant or benign
stricture,
– When endoscopy is contra indicated, or unable to
localize safe puncture site.

35. • Per cutaneously pass a needle through the left lobe
of the liver, into the lumen of the remnant stomach,
 filled with air and contrast.
• Needle put in stomach at different site.
• Then with seldinger method put the FT.

36. • Gauderer MWL, Stellato TA. Gastrostomies:
• Evalution, techniques, indications and complications.
• Curr Prob Surg 1986; 23: 661-719.

37. JEJUNOSTOMY
• This is commonly performed surgical enterostomy for EN.
– Can be used in patients who have had a gastrectomy.
– When stomach is to be used for surgery later on like in
ca esophagus.
– Usually placed at the time of other surgery, although
laparascopic placement has also been described.

38. Needle jejunostomy
– by inserting a 14- to 16G needle is to create a
subserosal tunnel approximately 30 to 40 cm
distal to the ligament of Treitz and the tip
redirected into the jejunal lumen.
– A 9F catheter is inserted through the needle and
advanced 30 to 40 cm distally.
– The needle is removed and the loop of jejunum is
anchored to the anterior abdominal wall with silk
sutures internally.

39. The Witzel technique
This is the gold standard for placing jejunostomy tube.
Laparoscopic Jejunostomy

40. SliC technique
• This technique is a variation on the introducer technique.
• Endoscopic access to the stomach is obtained in the standard
fashion and the ideal location for percutaneous access is
determined.
• Instead of placing an introducer and outer peel-away sheath, a 7- to
8-mm radially expanding Step trocar is used to penetrate the
abdominal wall and gain access to the stomach.
• A PEG tube is then inserted through this trocar.
• The trocar is removed and the tube is secured in the usual fashion.
• This method is advantageous because it allows for the placement of
a larger-diameter 20F Malecot tube that is more resistant to
plugging and accidental removal.
• In addition, abdominal or PEG site seeding of oropharyngeal
cancers is avoided with this technique as it circumvents dragging
the tube through the oral cavity or esophagus

41. MINI-LAPAROSCOPICALLY GUIDED
PERCUTANEOUS GASTROSTOMY
• In patients in whom
– transillumination of the abdominal wall is not possible,
– who have had previous gastrectomies,
– who have failed radiologic gastrostomy tube placement,
• First pneumoperitoneum established.
• With simultaneous use of laparoscope and endoscope, the
optimal insertion point is determined in the stomach or
jejunum.

42. PERCUTANEOUS TRANSESOPHAGEAL
GASTROSTOMY TUBE
• First reported by Oishi in Japan in 1998, the PTEG technique allows for
placement of a gastrostomy tube via the cervical esophagus, which avoids
going through the abdominal wall.
• It is especially useful in the
– presence of tense ascites,
– morbid obesity,
– distended loops of bowel anterior to the stomach, or
– in patients with carcinomatosis.
• The patient is placed in a supine position and conscious sedation
administered.
• A guide wire is inserted through the nose and into the esophagus.
• Correct positioning of the wire is confirmed via fluoroscopy. A rupture-free
balloon (RFB) is advanced over the wire into the distal esophagus and then
inflated with approximately 20 mL of dilute contrast and retracted until
resistance is met at the cricopharyngeus.
• Ultrasound is used to verify position of the balloon.
• The optimal puncture site is determined by trans cutaneous ultrasound
and the overlying skin is anesthetized.

43. • A small needle with an outer sheath is placed through the left neck and into the
RFB under ultrasound and fluoroscopic guidance.
• Aspiration of contrast material into the syringe confirms proper placement of the
needle.
• The needle is removed and a guidewire is inserted through the sheath into the
balloon. The sheath is removed and the guidewire is grasped at skin level and the
RFB delated and advanced into the distal esophagus, allowing the cervical
guidewire to come out of the lumen of the balloon and remain in the esophagus.26
• The guidewire is then removed from the balloon and advanced into the stomach.
The original nasal guidewire and the RFB are then removed.
• A small incision is made over the cervical guidewire and a 16F dilator with an outer
peel-away sheath is placed over the wire into the esophageal lumen to upsize the
percutaneous
• esophageal access. The wire and dilator are removed and the PTEG balloon
catheter is advanced into the stomach.
• Once in the stomach, the balloon is inflated and pulled upward with the tip of the
catheter resting just below the GEJ. After catheter placement, contrast injection
conirms correct placement.

44. DIRECT PERCUTANEOUS ENDOSCOPIC
JEJUNOSTOMY
• It is indicated in patients who are unable to tolerate oral nutrition
and in whom conventional percutaneous endoscopic gastrostomy
insertion was unsuccessful or inappropriate (secondary to gastric
resection, malignancy, or dysmotility).
• The procedure may be performed with the use of conscious sedation.
• The procedure begins with the passing of the endoscope into the first
loop of the jejunum and confirming its position by transillumination
and finger indentation in the left upper quadrant.
• A 4-cm 21-gauge pilot needle is advanced through the abdominal
wall and used to locate the jejunal lumen.
• Intermittent fluoroscopy may be used to help guide the needle into
the gut lumen.
• After the appropriate puncture site has been determined, a drainage
access needle is advanced alongside of the pilot needle into the
bowel lumen where it may be snared. At this point, the procedure
proceeds in the same manner as a pull PEG tube insertion.

45. MAGNETICALLY GUIDED FEEDING TUBES
• This procedure may be performed at the patient’s bedside by
one person without the use of fluoroscopy or endoscopy.
• The feeding tube is placed via the nares into the stomach and
the position confirmed by auscultating over the epigastrium
during air insuflation.
• A hand-held magnet is then placed externally over the
epigastrium to establish magnetic coupling to the specialized
feeding tube, which contains a small earth magnet at its tip.
• The external magnet is then moved slowly across the surface of
the abdomen to the right upper quadrant, then inferiorly, and
initially toward the midline to follow the curvature of the
duodenum. A plain abdominal
• radiograph is used to confirm proper position.

46. Administration
and
feeding protocol

47. • Enteral feedings should be started postoperatively in
surgical patients without waiting for flatus or a bowel
movement, (initiated within 24-48 hours)
• A PEG tube may be utilized for feedings within
several hours of placement, (within 2 hours in adults
and 6 hours in infants and children.)

48. • Delivery method and initiation and advancement of
EN regimens on
– patient condition,
– age,
– enteral route (gastric vs small bowel),
– Nutrition requirements
– GI status

49. • Choose full strength, isotonic formulas for initial
feeding regimen.
• Diluting formulas may increase the risk of microbial
contamination  intolerance due to diarrhea.

50. • Gastric feeding and stable patients.
– Initiate with full strength formula @ 50 ml/hr, X 3-
8 times bolus/gravity method.
– Increase upto 50-100ml/hr every 10-12 hrs till
goal volume.(usually 24-48hrs)

51. • Small-bowel feedings and
• Gastric feedings in critically ill patients or severly
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 hrly till goal reached.

52. • Elevate the backrest to a minimum of 30º, and
preferably to 45º, for all patients receiving EN unless
a medical contraindication exists.

53. • Flush feeding tubes with
– 30 mL of water every 4 hours during continuous
feeding.
– Before and after bolus/intermittent feedings in an
adult patient.
– after measuring GRV.
• Sterile water is usually recommended, for flushing
and mixing medications.

54. GRV
• No adequately powered studies have demonstrated
that elevated GRVs are reliable markers for increased
risk of aspiration pneumonia.
• “the elevated residual volumes by themselves have
little clinical meaning and that only when combined
with vomiting, sepsis, sedation, or the need for
pressor agents does the correlation with worsening
patient outcome emerge.”
» McClave SA, Lukan JE, Stefater JA, et al. Poor validity of
residual volume as a marker for risk of aspiration in
critically ill patients. Crit Care Med. 2005;33:324-330.

55. • GRV every 4 hlry for first 48 hrs till goal reached 
Then 6-8 hrly, if patient stable.
• If patient is critically ill, GRV measurment should be 4
hrly.
• If the GRV is > 250 mL x2 times a promotility agent
should be considered in adult patients.

56. • A GRV >500 mL  holding EN and reassessing
patient tolerance by use of an established algorithm
including physical assessment, GI assessment,
evaluation of glycemic control, minimization of
sedation, and consideration of promotility 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.

57. Administration
• Bolus
• Intermittent
• Continuous

58. Bolus feeding
• Infusion of up to 500 ml of enteral formula into the
stomach over 15 (5-20 ) minutes, usually by gravity
or with a large-bore syringe.
Indications:
• Recommended for gastric feedings
• Requires intact gag reflex
• Normal gastric function.

59. Advantages:
• More physiologic
• Enteral pump not
required
• Inexpensive and easy
administration
• Limits feeding time so
patient is free to
ambulate,
• Makes it more likely
patient will receive full
amount of formula
Disadvantages:
• Increases risk for
aspiration
• Hypertonic, high fat, or
high fiber formulas may
delay gastric emptying
or result in osmotic
diarrhea

60. Continuous Feedings
• It is administered through pump or gravity, usually over
8- 24 hrs continuosly .
Indications:
• Initiation of feedings in acutely ill patients
• Feeding into small bowel
• Intolerance to other feeding technique.

61. Advantages:
• May improve tolerance
• May reduce risk of
aspiration
• Increased time for
nutrient absorption
Disadvantages:
• May reduce 24-hour
infusion
• May restrict
ambulation
• More expensive for
home support
• Pumps are required

62. Intermittent Feedings
Definition
• Enteral formula administered at specified times
throughout the day; generally in smaller volume and
at slower rate than a bolus feeding but in larger
volume and faster rate than continuous drip feeding
• Typically 200-300 ml is given over 30-60 minutes q 4-
6 hours
• Precede and follow with 30-ml flush of tap water
Indications:
• Intolerance to bolus administration
• Initiation of support without pump
• Preparation of patient for rehab services or discharge
to home

63. Advantages:
• May enhance quality
of life
– Allows greater
mobility between
feedings
– More physiologic
– May be better
tolerated than
bolus
Disadvantages:
• Increased risk for
aspiration
• Gastric distention
• Delayed gastric emptying

64. Open System
• Product is decanted into
a feeding bag
• Allows modulars such as
protein and fiber to be
added to feeding
formulas
• Less waste in unstable
patients (maybe)
• Shortens hang time
• Increases nursing time
• Increased risk of
contamination

65. Closed System or Ready to Hang
• Containers sterile until spiked for
hanging
• Can be used for continuous or bolus
delivery
• No flexibility in formula additives
• Less nursing time
• Increases safe hang time
• Less risk of contamination
• More expensive than canned formula

66. Closed vs Open System
Open System
• Hang time 8 hours for
decanted formula; 4
hours for formula
mixtures
• Feeding bag and tubing
should be rinsed each
time formula replenished
• Contaminated feedings
are associated with pt
morbidity
Closed System
• Hang time 24-48 hours
based on mfr
recommendations
• Y port can be used to
deliver additional fluid
and modulars
• May result in less
formula waste as open
system formula should
be discarded p 8 hours

67. Enteral Feeding Complications
• Mechanical
• Gastrointestinal
• Metabolic
• Infectious

68. Mechanical
• Feeding tube obstruction
• Feeding tube dislodged
• Nasal irritation
• Skin irritation/excoriation at entrerostomy site

69. Causes of Feeding Tube Obstruction
• Concentrated, viscous, and fiber-containing feeding
products
• Tube feeding contamination
• Checking of gastric residuals
• Small diameter tubes
• Powdered or crushed medication flushed through
tubes
• Acidic or alkaline medications passed through tubes
• Tubes not routinely flushed after feedings are
stopped

70. Prevention of Feeding Tube Obstruction
• Flush the feeding tube, especially before and after
medication administration and bolus/intermittent
feedings
• Use liquid formulations of medicines where possible
(but be careful of osmolarity)
• Do not mix medications with enteral feedings unless
shown to be compatible
• Avoid crushing sustained-release or enteric-coated
tablets

71. Treatment of
Feeding Tube Obstruction
• Declog with irrigants (warm water) or sodium
bicarbonate/pancrealipase mixture or by mechanical
means
• Cola beverages, cranberry juice, and tea not
recommended
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition, 2005

72. Aspiration
• Reported incidence of aspiration in tubefed patients
varies from .8% to 95%. Clinically significant
aspiration 5% gastric-fed pts
• Many aspiration events are “silent” and often involve
oropharyngeal secretions
• Symptoms include dyspnea, tachycardia, wheezing,
rales, anxiety, agitation, cyanosis
• May lead to aspiration pneumonia

73. Aspiration Prevention
• Keep head of bed elevated 30-45 degrees during and
30-40 minutes after feedings
• Small, frequent feedings or continuous drip
• Use of promotility agents
• Monitoring of gastric residuals may be helpful in
identifying delayed gastric emptying and increased
risk of aspiration.
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition,
2005

74. Gastrointestinal Complications
• Diarrhea
• Constipation
• Gastric distention/bloating
• Gastric residuals/delayed gastric emptying
• Nausea/vomiting

75. Diarrhea
• Definition:
– >500 ml every 8 hours
– or more than 3 stools a day for at least two consecutive
days, Relates more to stool consistency than frequency
• Diarrhea was a common consequence of enteral
feedings when hyperosmolar feedings were routinely
delivered via syringe
• Occurs in 2 to 63% of enterally-fed pts depending on
how defined

76. Causes/Treatments of Diarrhea
• Intestinal atrophy due to malnutrition
• Bolus feeding in the small intestine: results in
dumping syndrome.
– Use an infusion pump to regulate flow
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd
Edition, 2005

77. Causes/Treatments of Diarrhea
• Bacterial overgrowth of intestinal tract or
contamination of the enteral feeding
– Avoid prolonged use of broad-spectrum
antibiotics
– Use clean technique and closed system in
handling enteral feedings
– Limit hang time of open system formulas to 8
hours (4 hours for mixtures)
– Change bag and tubing per protocol
– Test for C difficile and other pathogens before
using anti-motility agents

78. Causes/Treatments of Diarrhea
• Steatorrhea: characterized by frothy, odiferous stools
that float on water; caused by fat intolerance
– Use lowfat enteral formula or one with higher
percentage of MCT; pancreatic enzymes may help
in pancreatic insufficiency

79. Causes/Treatments of Diarrhea
• Lactose intolerance
– Most enteral products are lactose free but this
may occur with initiation of full liquid diet.
Eliminate milk and dairy products
• Drug-induced diarrhea
– Meds may cause up to 61% of diarrhea in tubefed
pts due to hypertonicity or direct laxative action
(magnesium, sorbitol, potassium), antibiotics.
The A.S.P.E.N. Nutrition Support Practice Manual, 2nd
Edition, 2005

80. Treatment of Diarrhea in General
• Add soluble fiber (such as banana flakes or
Benefiber) or insoluble fiber such as psillium
• Consider an enteral formula with added fiber
• Use an antidiarrheal agent (loperamide,
diphenoxylate, paregoric, octreotide)
• Change the formula

81. Nausea/Vomiting
• 20% of patients on EN report nausea/vomiting
• Often related to delayed gastric emptying caused by
hypotension, sepsis, stress, anesthesia, medications
(analgesics and anticholinergics), surgery

82. Nausea/Vomiting Treatment
• Consider reducing/discontinuing narcotic
medications
• Switch to a low fat formula
• Administer feeding solution at room temperature
• Reduce rate of infusion by 20-25 ml/hr
• Administer prokinetic agent (metoclopramide,
erythromycin, domperidone, bethanechol)
• Check gastric residuals
• Consider antiemetics

83. Metabolic
• Fluid and Electrolyte abnormalities
• Glucose intolerance
• Ca++, Mg++, PO4 abnormalities

84. Fluid and Electrolyte Disturbances
• May result from long term nutrition deficits, acute
stress, medications, medical conditions, improper
nutrient prescription
• Electrolytes lost via stool, urine, ostomy or fistula
drainage

85. Hyperglycemia
• Often reflects acute stress, infection, medications
(especially steroids) or latent diabetes
• Macronutrient distribution: is generally not the
primary issue; most enteral feeding formulas fall
within established guidelines; could try formula
lower in carbohydrate
• Insulin management

86. Refeeding Syndrome
• At risk: when refeeding those with marginal body
nutrient stores, stressed, depleted patients, those
who have been unfed for 7-10 days, persons with
anorexia nervosa, chronic alcoholism, weight loss.
• Symptoms: Hypokalemia, hypophosphatemia and
hypomagnesemia; cardiac arrhythmias, heart failure;
acute respiratory failure

87. Refeeding Syndrome
• Correct electrolyte abnormalities (via oral, enteral,
parenteral route) before initiating nutrition support
• Administer volume and energy slowly
• Monitor pulse rate, intake and output, and
electrolyte levels
• Provide appropriate vitamin supplementation
• Avoid overfeeding

88. Infectious Complications
• Formula contamination
• Unsanitary equipment
• Failure to follow appropriate protocols re handling of
enteral feedings/changing of bags and tubing

89. Monitoring of Patients on EN
• Electrolytes
• BUN/Cr
• Albumin/prealbumin
• Ca++, PO4, Mg++
• Weight
• Input/output
• Vital signs
• Stool frequency/consistency
• Abdominal examination

90. SUMMARY
• Mal nutrition is highly prevalent in developing
country like india.
• Knowledge of enteral nutrition is essential for
treating personnel.
• Indivualize feeding methods, protocols
• Each institution should define an ongoing quality
control process for EN formula preparation,
distribution, storage, handling, and administration.