2. What's enteral nutrition?
• Enteral nutrition is a way of providing nutrition to
the patients who are unable to consume an
adequate oral intake but have at least a partially
functional GI tract
3. Indications of EN
Decreased oral intake <50% for 7-10 days
Malnourished unable to eat >5 days
Normal nourished patients unable to eat > 5 days
Adaptive phase of short bowel syndrome
Following severe trauma or burns
Inability to take oral feedings due to head or neck trauma.
Prolonged anorexia
Facial or oesophageal structural abnormalities
Coma
4. Contraindications for EN
Severe acute pancreatitis
High output proximal fistula
Inability to gain access
Intractable vomiting or diarrhea
peritonitis
Severe diarrhea
Inability to gain access
Ileus
Intestinal obstruction
Severe G.I. Bleed
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143
9. Nasogastric Tubes
Definition
• A tube inserted through the nasal passage into the
stomach
Indications:
• Short term feedings required
• Intact gag reflex
• Gastric function not compromised
• Low risk for aspiration
10. Nasogastric Tubes
Advantages:
• Ease of tube placement
• Surgery not required
• Easy to check gastric residuals
• Accommodates various administration techniques
11. Nasogastric Tubes
Disadvantages:
• Increases risk of aspiration
• Not suitable for patients with compromised gastric
function
• May promote nasal necrosis and esophagitis
• Impacts patient quality of life
12. Nasoduodenal/Jejunal
Definition
• A tube inserted through the nasal passage through
the stomach into the duodenum or jejunum
Indications:
• High risk of aspiration
• Gastric function compromised
15. Orogastric
• Tube is placed through mouth and into stomach
• Often used in premature and small infants as they
are nasal breathers
• Not tolerated by alert patients; tubes may be
damaged by teeth
17. Gastrostomy
Definition
• A feeding tube that passes into the stomach through
the abdominal wall. May be placed surgically or
endoscopically
Indications:
• Long-term support planned
• Gastric function not compromised
• Intact gag reflex present
21. Jejunostomy
Definition
• A feeding tube that passes into the jejunum through
the abdominal wall. May be placed endoscopically or
surgically
Indications:
• Long-term feeding option for patients at high risk for
aspiration or with compromised gastric function
22. Jejunostomy
Advantages:
• Post-op feedings may be initiated immediately
• Decreased risk of aspiration
• Suitable option for patients with compromised
gastric function
• Stable patients can tolerate intermittent feedings
23. Jejunostomy
Disadvantages:
• Requires stoma care
• Potential problems related to leakage or tube
dislodgement/clogging may arise
• May restrict ambulation
• Bolus feedings inappropriate (stable patients may
tolerate intermittent feedings)
29. Metabolic
• Fluid and Electrolyte abnormalities
• Glucose intolerance
• Ca++
, Mg++
, PO4 abnormalities
• Other
30. Infectious Complications
• Formula contamination
• Unsanitary equipment
• Failure to follow appropriate protocols re handling of
enteral feedings/changing of bags and tubing
31. Monitoring of Patients on EN
• Electrolytes
• BUN/Cr
• Albumin/prealbumin
• Ca++
, PO4, Mg++
• Weight
• Input/output
• Vital signs
• Stool frequency/consistency
• Abdominal examination
32. PARENTERAL NUTRITION
• This refers to nutrition directly into the
systemic circulation, bypassing the
gastro-intestinal tract (GIT)
35. PERIPHERAL PARENTERAL NUTRITION
• This refers to use of peripheral veins to provide a
solution that meet nutrient needs for infusion. It has
lower dextrose (5% to 10% final concentration) and
amino acid (5% final concentration)
• PPN may be used in patients with mild or moderate
malnutrition to provide partial or total nutrition
support when they are not able to ingest adequate
calories orally or enterally or when central vein PN is
not feasible
36. TOTAL PARENTERAL NUTRITION
• CPN is often referred to as “Total Parenteral
Nutrition” since the entire nutrient needs of the
patient may be delivered by this route. It requires a
central venous system for long term infusions
37. INDICATIONS FOR TPN
• Gastrointestinal fistula
• Bowel obstruction
• GI non functioning
• NPO >5 days
• GI fistula
• Acute pancreatitis
• Short bowel syndrome
• Nutritional needs not met; patient refuses food
39. Summary of Parenteral Nutrition Guidelines in
the Critical Care Unit
1. All patients receiving less than target in 3 days enterally to
receive PN within 24 to 48 hours of admission once
haemodynamically stable
2. PE requirements to be calculated at 25 kcal/kg/d and increased
to target over 2 – 3 days
3. Carbohydrate to be given at a minimum of 2g/kg/d as glucose,
monitor blood sugars (BS), BS >10mmol/l to be avoided
4. Lipids to be given at a dose of 0.7 – 1.5g/kg/d, EFA, EPA and
DHA, live oil based, fish oil added
5. Protein to be given at 1.3 –1.5g ideal body weight (IBW)
6. Amino acid solution should contain glutamine at a dose of 0.2
-.04g /kg/Bodyweight/d (0.3 – 0.6g alanyl-glutamine dipeptide)
40. 7. Daily dose of multivitamin and trace element to be adhered to
8. PN admixtures to be administered as a complete All in One
bag. If there is evidence of PEM on admission and enteral
nutrition is not feasible, it is appropriate to initiate parenteral
nutrition as soon as possible following admission and
adequate resuscitation
9. If a patient is expected to undergo major upper GI surgery
and EN is not feasible, PN should be provided under specific
conditions: If the patient is malnourished PN to be given 5-7
days preoperatively and continued into the postoperative
period
10. Wean PN gradually
11. Discontinue once the patient is able to adequately tolerate
60% of caloric requirements enterally