Gastroenterology In Critical Care
Nutritional Support In Critical Care
Enteral Nutritional Support
nursebob© 07/25/10
Enteral Nutritional Support
INDICATIONS
· Functioning GI tract but inability or unwillingness to consume
nutrients
ADVANTAGES
Preferred route for patients with functional GI tract
Fewer complications than parenteral routeReduced incidence of sepsis
Absorptive ability of GI tract maintained
Less expensive
TYPES AND CHOICE OF TUBES
Nasogastric
Nasoduodenal
Esophagostomy
Gastrostomy (PEG)
Jejunostomy
Choice
Small-gauge tube or tube that is placed below the gastroesophageal sphincter (such as PEG tube or jejunostomy tube) preferred
Short-term (<6 weeks): nasogastric or nasointestinal tube
· Long-term (>6 weeks): gastrostomy or jejunostomy
TYPES AND CHOICE OF FORMULAS
Elemental or defined (clear liquid, minimal residue, lactose-free, meal replacement, and supplements)
Necessary to note osmolality (isotonic is 250 to 350 mOsm/L)
Necessary to note calorie concentration (most 1 kcallml, but some critical care solutions such as Magnacal have 2 kcal/ml)Types
Complete isotonic balanced liquid nutrition (e.g., Osmolite, Isocal)
Complete balanced liquid nutrition (e.g., Ensure, Sustacal)
High-calorie complete balanced liquid nutrition (e.g., Ensure Plus)
High-nitrogen liquid nutrition (e.g., Magnacal, Ensure HN, Osmolite HN, Sustacal HC, Replete)
· Fiber-containing formulas (e.g., Ensure with fiber, Jevity, Sustacal with fiber)
a Partially hydrolyzed or elemental diets (e.g., Criticare HN, Impact, Vivonex)
· Specialized nutrition (e.g., Pulmocare, Glucerna, Suplena)
PATTERN OF DELIVERY
Intermittent (cannot be used below the pylorus)
Continuous
MONITOR
· Intake and output
· Daily weight
· Serum glucose q 6 hours
· Electrolytes
· BUN
· Liver function studies
GENERAL GUIDELINES
· Placement verified with x-ray, injection of air with auscultation over stomach, aspiration of gastric contents
· Continuous infusion via an infusion pump
· Residual volume checked every 4 hours or before next intermittent feeding; if residual greater than 100-150 mi, feeding delayed for at
least 1 hour and then checked again
· Room temperature fluids (but should be at room temperature no more than 4 hours)
· Initially 0.25-0.50 strength at slow rate; gradually increased
· Free water in volume equal to 0.25-0.50 volume of feeding to prevent hyperosmolality
· HOB elevated at least 30 degrees during and after intermittent feeding; continuously for continuous feeding
COMPLICATIONS OF ENTERAL ALIMENTATION
Endotracheal aspiration of tube feeding
HOB elevated at all times if feeding is continuous; tracheal cuff kept inflated
Metabolic complications: hyperosmolar, hyperglycemic, nonketotic dehydration; fluid overload; nausea and vomiting; diarrhea
Serum glucose monitored as necessary; exogenous insulin as indicated
Diarrhea avoided through proper choice of feeding and slow, constant infusion; reasons for diarrhea:
- Decreased plasma colloidal oncotic pressure (COP) caused by low serum proteins
-Bacterial contamination
-Hypertonicity
·-Alteration in normal flora from antibiotics and proliferation of Clostridium difficile
--Treated with metronidazole (Flagyl), vancomycin
--Yogurt sometimes used to restore normal flora if patient is not immunosuppressed
Reference: Nursebob's notes
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