Transcript NUTRIENTS AND ENERGY METABOLISM

Implementing Enteral
Nutrition: Formula Selection
and Administration
Objectives
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To describe the categories of enteral formulas
To explain how to choose the appropriate category of
enteral formula for each patient’s disease state
To describe the various methods for delivering enteral
nutrition and how to choose the most appropriate
formula for each situation
Enteral Formulas: Categories
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Polymeric formulas
– Commercial
– Blenderized
Oligomeric formulas
Disease-specific formulas
Modular formulas (concentrated protein and
carbohydrate preparations)
Polymeric Formulas
Contain intact macronutrients and require digestion:
 Intact proteins
 Polysaccharides
 Disaccharides
 Polyunsaturated fatty acids (PUFA)
 Medium-chain triglycerides (MCT)
Polymeric Formulas:
Benefits of Commercial Formulas
Commercial Formulas
Blenderized Formulas
Uniform contents
Sterile
Daily nutrient variability
Non-sterile; high bacterial content
and other pathogens
High viscosity
Does not provide adequate caloric
density
Low viscosity
Lactose free
Defined caloric density
Gallagher-Allred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:268-273
Commercial Polymeric Formulas:
Selection
Features
• Protein, caloric density, and osmolality vary
• With or without added fiber
• Most are lactose- and gluten-free
• Nutritionally complete in sufficient quantities
Patient must have:
• Functional GI tract
• Normal digestion
• Normal absorption
Oligomeric Formula Categories
Hydrolyzed macronutrients facilitate digestion and absorption
Components
 Amino acids
– Glutamine
– Arginine
 Peptides
 Monosaccharides
 Disaccharides
 Glucose polymers
 Polyunsaturated fatty acids
 Medium-chain triglycerides
 Vitamins and minerals
Also called “elemental,” “semi-elemental,” “hydrolyzed”, or
“chemically defined” formula.
In: Rombeau JL, Rolandelli RH, eds. Clinical Nutrition: Enteral and Tube Feeding. 3rd ed. WB Saunders
Company; 1997
Oligomeric Formulas: Selection
Indications for Use:
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Inflammatory bowel disease
Pancreatic insufficiency
Malabsorption
Short bowel syndrome
Radiation enteritis
Early enteral feeding
Intolerance to polymeric formula
Enteral Formula Selection:
Disease-Specific Formulas
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Pulmonary disease
Glucose intolerance
Cancer-induced weight loss
Hepatic insufficiency
Critical care
Renal failure
HIV+/AIDS
Cabre E, Gassull MA. Nutrition 1992;8:1-9.
Disease-Specific Formula Selection:
Pulmonary Disease (Chronic)
Pulmonary disease with CO2 retention
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Decreased carbohydrate content
Increased fat content
High caloric density
Intact proteins
Fiber supplement
Brown RO et al. Clin Phar 1984;3:152-161; Askanazi J et al. Anesthesiology 1981;54:373-377
Deitel M et al. J Am Coll Nut 1983;2:25-32
Disease-Specific Formula Selection:
Glucose Intolerance
Glucose Intolerance
• Diabetes mellitus
– Type I
– Type II
• Hyperglycemia associated with:
– Pancreatic disease
– Drug and chemical-induced
– Insulin receptor abnormalities
Cabre E, Gassull MA. Nutrition 1992;8:1-9
– Hormonal alterations
– Genetic syndromes
– Metabolic stress
Disease-Specific Formula Selection:
Glucose Intolerance
Recommendations
• Low carbohydrate content
– Monosaccharides (fructose)
– Glucose polymers
• Increased monounsaturated fat (MUFA)
• Added fiber
Franz MJ, et al. Diabetes Care 1994;17:490-518; J Am Diet Assoc 1994;94:504-506
Diabetes Care 1997;20:514-517
Disease-Specific Formula Selection:
Cancer-Induced Weight Loss
Cancer-Induced Weight Loss
• Complex metabolic syndrome - anorexia, fatigue,
early satiety
• Significant weight loss & muscle wasting
• Etiology is multifactorial
– Pro-inflammatory cytokines
– Acute phase response
– Abnormal metabolism
– Proteolysis inducing factor (PIF)
• Cannot correct by additional calories alone
Negative
Prognosis
&
QOL
Disease-Specific Formula Selection:
Cancer-Induced Weight Loss
Recommendations
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High protein and Zn to build muscle
Low fat to avoid early satiety
Low in sucrose for better patient acceptance
High in fermentable fibers
Eicosapentaenoic acid (EPA)
Antioxidants (vitamins A, C, E and Se)
Folate and iron for anemia
Disease-Specific Formula Selection:
Hepatic Disease
Hepatic Insufficiency
• Altered protein metabolism and protein loss
• Altered carbohydrate metabolism
– glucose intolerance
– low hepatic glycogen stores
• Malabsorption of fat and fat-soluble vitamins
• Inability to elongate or desaturate essential fatty acids
• Vitamin and mineral deficiencies (e.g., B-complex and Zn)
• Impaired urea synthesis with hyperammonemia and hepatic
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encephalopathy
Fluid and sodium retention
Reduced appetite/oral intake and taste impairment
Disease-Specific Formula Selection:
Hepatic Disease
Recommendations
• High caloric density with low sodium content
• Moderately high calorie:nitrogen ratio
• High in branched chain AAs and low in aromatic AAs
• Non-digestible soluble fiber
• Long-chain fatty acids and supplemental MCT
• Supplemented with fat soluble vitamins, Zn, folic acid and B
complex vitamins
• Low copper, iron, manganese content
Disease-Specific Formula Selection:
Critical Care
Types of Injury
• Elective surgery
• Minor trauma
• Burn
• Pressure ulcer
Patient Conditions
• Sepsis
• Inflammatory
Disease-Specific Formula Selection:
Critical Care
Nutrient Choices
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Hydrolyzed or intact proteins
Glutamine
Arginine
Taurine, Carnitine
Eicosapentaenoic acid (EPA), Gamma-linolenic Acid (GLA)
Antioxidants
Poullain et al. JPEN 1989;13:382-386; Lacey JM et al. Nutr Rev 1990;48:297-309
Barbul A et al. Surgery 1990;108:331-337
Disease-Specific Formula Selection:
Critical Care (Mechanical Ventilation)
Lung Injury / SIRS / ARDS
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Eicosapentaenoic acid (EPA)
Gamma-linolenic Acid (GLA)
Antioxidants
High caloric density
No arginine supplementation
Gadek J. Chest 1998;114:277S; Gadek J. Crit Care Med 1999;27:1409-1420;
Pacht ER, et al. Crit Care Med 2003;31:491-500
Disease-Specific Formula Selection:
Critical Care
Arginine (a double-edged sword)
• Conditionally essential nutrient that enhances wound
healing
• Supports immune system and is associated with
reduced infectious complications
“Giving arginine to a septic patient is like putting gasoline on an
already burning fire.”
- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL
Disease-Specific Formula Selection:
Renal Disease
Acute or Chronic Renal Disease
• Increased BUN and creatinine
• Increase in serum electrolytes:
– Na
– K
– PO4
– Mg
Kopple JD. In: Shils ME et al eds. Modern Nutrition in Health and Disease. 8th ed. Philadelphia: Lea &
Febiger; 1994:1102-1134; Blumenkranz MJ et al. Kidney Int 1982;21:849-851
Disease-Specific Formula Selection:
Renal Disease
Recommendations
• Protein content
– Predialysis: 30 g/L
– Dialysis:
70 g/L
• Low electrolyte content
• High caloric density
Monson P, et al. J Renal Nutr 1994;4:58-77
ASPEN Board of Directors. JPEN 2002;26 Suppl 1
Disease-Specific Formula Selection:
Advanced AIDS (with weight loss)
Advanced AIDS
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Weight loss > 5% below normal
CD4 < 400
Serum albumin < 3.0 g/dL
Opportunistic infection
Diarrhea
Impaired immune function
Raiten DJ. Nutrition and HIV Infection. Department of Health and Human Services, Washington D.C.
Grunfeld C et al. Sem Gastro Dis 1991; Kotler DP et al. Am J Clin Nutr 1985
Disease-Specific Formula Selection:
Advanced AIDS (with weight loss)
Recommendations
• Increased protein
• Low fat for improved tolerance
• Added fiber
• EPA to down regulate metabolic changes associated
with cachexia
• Increased levels of antioxidants (beta-carotene, vitamin
E, C) and B vitamins (B6, B12)
Baum MK, et al. Ann N Y Acad Sci 1992;669:165-174
Raiten DJ. Nutrition and HIV Infection. Dept. of Health and Human Services , Washington D.C.
Enteral Formula: Selection
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Metabolic requirements
Patient condition or status
Pre-existing conditions
GI function
Enteral Formula: Selection
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The physician should know the formula’s nutrient profile
to meet specific patient needs
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Understand the clinical evidence supporting specific
formula use
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Data obtained exclusively from animal models may or
may not apply to the clinical setting
Enteral Formula: Oral Administration
Oral Supplementation
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Indicated especially for patients with malnutrition or at risk
for weight loss
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When given between meals, does not reduce intake of
other foods
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Frequently stimulates increased intake of other foods
Thickened oral supplements are useful for patients with
dysphagia
Benefits of Oral Supplements
Improvement in Oral Intake
Proportional Increase
250
200
Without Supplement
With Supplement
150
100
50
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Daily Energy
(kcal)
Daily Protein (g)
Daily Calcium
(mg)
Delmi M et al. Lancet 1990;335:1013-1016
Enteral Formula: Tube Feeding
Type:
• Intermittent
• Continuous:
– 24 hours / day
– During part of the day or at night
Infusion Method:
• Gravity
• Infusion pump
Gottschlich MN, Shronts EP, et al. Defined formula diets. In: Rombeau JL, Rolandelli, eds. Clinical
Nutrition: Enteral and Tube Feeding. W B Saunders; 1997; Giocon JO et al. JPEN 1992;16:525-528
Enteral Formula: Administration
Enteral Feeding
Intermittent
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Resembles normal feeding and digestion patterns
250-500 mL of formula
Administered over 30-60 minutes
5-8 times daily
Enteral Formula: Administration
Continuous
Plan 1
Beginning:
Progress:
Plan 2
Beginning:
Progress:
Day 1: 1000 mL over 24 hours
Day 2: 1500 mL over 24 hours
Day 3: final volume according to needs
25 mL/h (first 12 hours)
50 mL/h for next 12 hours
rate according to needs
Enteral Formula: Administration
Infusion Pump
Indications
Gravity Infusion
Indications
 Small intestine feeding
 Fluid restrictions
 Risk of aspiration
 Need for precise flow rate
 Nocturnal feeding
 Infants and small children
 Suitable for intermittent
feeding
 Ambulatory patients
 Gastric feeding
Enteral Formula: Administration
Summary
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Intermittent feeding
Continuous feeding
ASPEN Board of Directors. JPEN 2002;26 Suppl 1: 34SA.
Summary
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Described the categories of enteral formulas
Explained how to select appropriate formulas
Described the methods of enteral nutrition
administration