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 route

Reduced 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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