PROTEIN REQUIREMENTS

 Tube Feedings: Enteral Nutrition

1. Indications for Enteral Nutrition: the preferred route - "If the gut works, use it"

• Mechanical GI tract dysfunction/disorders - may have normal digestive & absorptive function with an oral/mechanical/physiological obstruction
• Facial/jaw injuries, head & neck CA, swallowing disorders, obstruction of the upper GI tract, GI tract fistulas, short bowel syndrome (feed beyond the obstruction/fistula)
• Metabolic GI tract dysfunction - may have impaired ability to digest & absorb nutrients
• Pancreatitis, infalmmatory bowel disease, radiation enteritis, chemotherapy
• Hypermetabolic conditions - may have increased energy & protein requirements that cannot be met with regular oral intake
• Major burns, trauma, sepsis, post-operative recovery following surgery

2. Contraindication for Enteral Therapy: GI tract not working

• Intractable vomiting
• Intestinal obstruction
• Upper GI tract hemorrhaging
• Severe, intractable diarrhea
• Severe, acute pancreatitis
• Expected need less than 5-10 days

3. Routes:

Short-term: Nasogastric, Nasoduodenal, Nasojejunal Long-term: Gastrostomy & Jejunostomy (surgically placed) and PEG - percutaneous-esophago-gastrostomy & PEJ - percutaneous-esophago-jejunostomy (endoscopically placed)

4. Tubes

Tube size: Consider viscosity of formula; select the smallest appropriate size for patient comfort. 8 French can generally be used for commercial formulas while the patient will need a 10-14 French for blenderized formulas.
Tube length: Depends on tube placement, with a 30" length for nasogastric feeding and 43" for nasoduodenal & nasojejunal feedings.

5. Selecting the formula: based on patient need

Consider each of the following factors:

• How well the GI tract is functioning and its capacity
• Underlying disease conditions
• Patient tolerance

Enteral Formula Categories

Category	Subcategory	Characteristics	Indications
Polymeric	Standard	Similar to average diet	Normal digestion
	High nitrogen	Protein>15% of total kcal	Catabolism Wound healing
	Caloric dense	2 kcal/ml	Fluid restriction Volume intolerance Electrolyte imbalance
	Fiber containing	Fiber 5-15 g/L	Regulation of bowel function
Monomeric	Partially hydrolyzed	One or more nutrients are hydrolyzed. Composition varies.	Impaired digestive and absorptive capacity
	Elemental
	Peptide based
Disease- Specific	Renal	Less protein, low electrolyte content	Renal failure
	Hepatic	High branched chain amino acids (valine, isoleucine and leucine, which are known as the stress amino acids), low aromatic amino acids (phenylalanine; tyrosine; tryptophan), low electrolyte content	Hepatic encephalopathy
	Pulmonary	Higher % of calories from fat instead of carbohydrates	ARDS
	Diabetic	Low carbohydrates	Diabetes mellitus
	Immune-enhancing	Arginine, glutamine, omega-3 fatty acid, antioxidants	Metabolic stress Immune dysfunction

from http://www.rxkinetics.com/tpntutorial/2_1.html (Note: N170 students responsible for Nutritional concepts and Enteral Nutrition ONLY)

6. Administration of feedings

• Bolus
• Intermittent
• Continuous

	Indications	Advantages	Disadvantages
Bolus	Noncritically ill patient Home TF Rehabilitation patient	Easy to administer Inexpensive Short administration time (usually 15 minutes)	Highest risk of aspiration, N/V, abdominal pain and distention, and diarrhea
Intermittent	Noncritically ill patient Home TF Rehabilitation patient	Flexibility in feeding schedule Inexpensive Feeding over shorter time allows patient more free time	Higher risk of aspiration, N/V, abdominal pain and distention, and diarrhea May require formula with more calories and protein
Continuous	Initiation of tube feedings Critically ill patient Small bowel feeding Intolerance of intermittent or bolus	Pump assisted Minimizes risk of high gastric residuals and aspiration Minimizes risk of metabolic abnormalities	Restricts ambulation Infused over 24 hours/day Increased cost (need pump)

7. Feedings started:

• In the past tube feedings that were hyperosmolar were diluted ½ strength - current recommendations are to leave the formula full strength and begin at a lower volume until tolerance is determined.
• Full strength if isotonic - DO NOT DILUTE ISOTONIC FORMULAS!
• Tube feeding is progressed until assessed nutrition goal reached
• If TF is diluted, do not advance concentration and rate at the same time

8. Tolerance

• Check gastric residuals
• Diarrhea
• Constipation
• Bloating and excess gas production

9. Sanitation

• bag and tubing is changed every 24 hours, but check your hospital protocol
• formula is administered at room temperature

TF should not be started until an X-ray shows the tube is in the proper place, then formula can be started
Head of bed (HOB) must be elevated at least 30° at all times.