Southern Philippines Medical Center
Nutrition and Dietetics Service
About the Lecturer
RONA CRISTY MATUNOG-RETULLA, RND
Nutritionist-Dietitian II
Clinical Dietitian, Enteral Feeding Unit Supervisor, Cancer Institute
• Graduate, Bachelor of Science in Nutrition and Dietetics
University of the Immaculate Conception
Certifications, Special Trainings, Recognitions:
• Trained Diabetes Educator
• Nutrition Care Process
• DPG – Nutrition Support
• PrOFILE Team Member
Southern Philippines Medical Center
Nutrition and Dietetics Service
ENTERAL NUTRITION
Subtitle of Presentation
Insert
RONA CRISTY MATUNOG-RETULLA, RND
Clinical Dietitian
photo
Enteral Feeding Unit Supervisor
here
Cancer Institute
Learning Agenda 1. The Evolution of Enteral Nutrition
2. Determining The Route of Enteral Nutrition
What we’ll 3. Candidates for Tube Feeding
discuss today 4. Types of Enteral Tubes
5. Gastric Versus Small-Bowel Feeding
6. Formula Delivery Methods
7. Enteral Formula Compositions
Learning Agenda
What we’ll 9 Disease – Specific Formulas
discuss today 10 Developing an EN Feeding Plan
11 Complication Monitoring
ENTERAL NUTRITION
Enteral Nutrition
• Refers to the delivery of nutrients into the gastrointestinal tract
either by mouth or through a feeding tube
• This includes food, oral supplements and formulas created
specifically to prevent malnutrition and accommodate nutrient
needs
• The development of EN has transformed nutritional care in a
hospital setting, where the inability to receive adequate nutrition
is common
Candidates for Tube Feeding
• Severe swallowing disorders
• Impaired motility in the upper GI tract
• GI obstructions and fistulas that can be bypassed with a feeding tube
• Certain types of intestinal surgeries
• Little or no appetite for extended periods, especially if the patient is
malnourished
• Extremely high nutrient requirements
• Mechanical ventilations
• Mental incapacitation due to confusion, neurological disorders or coma
THE EVOLUTION OF
ENTERAL NUTRITION
THE EVOLUTION OF ENTERAL NUTRITION
• 1910 – The first nasoduodenal tube was placed , with a formula of raw egg, milk and lactose
• 1918 – the first reported jejunal feeding took place using a formula of peptonized milk, dextrose and
whiskey
• 1950 – the commercial formula was used it was this time that flexible polyethylene tubes were developed
• 1970 – formulation of more synthetic tube feeds; low-residue and lactose –free TFs with a range of
osmolalities
• 1980 – EN resurged and became more clinically formalized to support nutrition and digestion, aid wound
healing , help the immune system and support the critically ill
- the first percutaneous endoscopic gastrostomy (PEG) tube was placed
THE EVOLUTION OF ENTERAL NUTRITION
• Tube placement capabilities became more advanced and TF products
proliferated. Formula began to be fortified with fiber, predigested to
include di- and tri-peptides, and enhanced to be more calorically dense.
• Product developers soon began to create more specialized formulas
specific to certain diseases.
• EN technology continued to advance in the 1990s
DETERMINING THE
ROUTE OF ENTERAL
NUTRITION
Determining the Route of Enteral Nutrition
The site and route of Enteral Nutrition should consider;
• Consider an individual’s anticipated length of feeding time
• Medical Condition or disease state
• If a patient requires tube feeding for 4 weeks or fewer, utilize a nasoenteric
tube. If a patient requires significantly more than 4 weeks of nutrition care,
a gastric or postpyloric percutaneous tube placement can be considered.
Determining the Route of Enteral Nutrition
• If a patient requires tube feeding for 4
weeks or fewer, utilize a nasoenteric
tube. If a patient requires significantly
more than 4 weeks of nutrition care, a
gastric or postpyloric percutaneous tube
placement can be considered.
SHORT – TERM
PLACEMENT
Short-Term Placement
• Nasogastric tube placement - is appropriate
for patients who have normal gastric function.
• Nasoduodenal tube feeding - tube is placed
from the nose, through the stomach, to the
duodenum of the small intestine
• Nasojejunal tube feedings - tube is placed
from the nose and advanced to the jejunum of
the small intestine.
Bedside Nasoenteral Technique
• Bedside Nasoenteral Technique
• bedside nasogastric tube
placement begins by obtaining a
small-bore tube, about 8 to 12
French (1 French [Fr] is equal to
0.33 mm in diameter). A large-
bore tube can also be used and is
thought to prevent clogging.
Bedside Nasoenteral Technique
• Bedside Nasoenteral Technique
• the small-bore tube can be more
comfortable for the patient
• The length of the tube is determined
by first measuring the distance from
the patient’s nose to the earlobe, and
then from the earlobe to the xiphoid.
• Prokinetics – medications that
promote motility3
Bedside Nasoenteral Technique
• Bedside Nasoenteral Technique
• technologies are used to ensure
that the nasogastric tube is placed
correctly;
• Radiographs
• chest x-ray
• magnetically guided feeding tubes
• electromagnetic imaging systems.
Endoscopic Nasoenteral Technique
• Nasoduodenal and nasojejunal tube
placements are most easily done
• A drag and pull technique is often
utilized, where a suture is placed at
the end of the nasoenteric tube and
pushed with the tube from the
patient’s nostril to the stomach.
Flouroscopic Nasoenteric Technique
• involves using x-ray imaging as a guide
when placing the feeding tube from
the nose to the stomach or small
intestine.
• Not used often due to radiation
exposure
LONG-TERM
PLACEMENT
Percutaneous Endoscopic Gastrostomy Technique
• Most common long-term tube
placement method
• Also called as the pull technique, an
endoscopic is placed into the
abdomen. The abdomen is then
transilluminated to find the optimal
spot for the tube placement and an
indentation is placed on that spot.
Percutaneous Endoscopic Jejunostomy Technique
• Percutaneous endoscopic jejunostomy
(PEJ) – performed if patient has gastric
complications
• Surgical methods – done in an open tube
procedure or with laparoscopy under
general anesthesia
• Open tube placement – small incision is
made on the abdomen so that
gastrostomy tube can enter
Types of Enteral
Tubes
Types of Enteral Tubes
• Polyvinyl chloride tubes - more rigid and allow simple access.
• They can also be used for gastric suctioning and administering medications.
• Polyurethane tubes are more pliable than polyvinyl chloride tubes
and cause less nasopharyngeal erosion, which gives greater comfort
to the patient.
Gastric Versus Small-
Bowel Feeding
Gastric Feeding
• Generally used if normal gastric function
• Gastric feedings are more physiologic
• Large-bore gastric tubes are used for less clogging
• More cost effective
Small- bowel Feeding
• Duodenal or jejunal feeding may be preferred if a patient has gastroparesis
or reflux, or is diagnosed with aspiration risk
• decrease the risk of microaspiration, as well as of aspiration pneumonia
• Aspiration – movement of fluid into the patient’s lungs
• Gastroparesis – (delayed gastric emptying) due to metabolic condition
or operation
Formula Delivery
Methods
Formula Delivery Methods
• Closed tube feeding system
- a ready-to-use container or
bag of formula is connected to
the patient’s feeding access.
- at room temperature for 24 to 48
hours
Formula Delivery Methods
• Open tube feeding system
- formula from a can or package is poured
into a separate container that is then
attached to the patient’s feeding access
point.
- should be at room temperature for 4 to 8
hours
Formula Delivery Methods
• Reconstituted formulas should hang for no
more than 4 hours
Continuous Feeding
• a common delivery method used for hospital patients.
• provides a slow infusion of feedings into the stomach or small intestine on an
hourly basis.
• decreases risk for aspiration and gastric distention.
• tends to be the most easily tolerated because of its gradual delivery of feeding
• may be preferred for those patients with gastrointestinal complications or severe
trauma
Continuous Feeding
• continuous feeds begin at 20 to 55 mL/hour for adults and 0.5 to 1
mL/kg for children (depending on age)
• Adults - rate increases by about 10 to 25 mL/hour every 4 to 24 hours
until the goal rate is achieved
• Children - this rate increases by 0.5 to 1 mL every 4 to 8 hours until
the goal rate is achieved
Intermittent Feeding
• delivered over a 20- to 60-minute interval, 4 to 6 times per
day.
• can be administered using an infusion pump or by using the
gravity drip method.
Bolus Feedings
• a specific volume of feeding is delivered over a short period
of time a certain number of times per day.
• preferable for stable patients because it does not rely on
pumps and devices
• are less commonly used due to presumed risk of aspiration
pneumonia and issues with tolerance
Enteral Formula
Compositions
Standard Formulas
Standards Formulas
• enteral formulas that contain mostly intact proteins and
polysaccharides; also called polymeric formulas
Carbohydrates
• Primary energy source of enteral formula
• Comprise 40% - 90% of the formula
• Sources include monosaccharides (glucose or fructose),
disaccharides (sucrose and maltose)
• Lactose is often omitted
•
Fats
• are a secondary energy source in formula composition.
• are also isotonic, which helps lower the osmolality of the
formula.
• Medium-chain fatty acids are absorbed directly into the
portal system and are easier to digest; however, they do not
provide essential fatty acids and so long-chain fatty acids
should be provided as well.
Protein
• come in different forms, depending on what is indicated by the
patient’s need and medical condition.
• Intact Proteins - are large in size and have limited impact on the osmolality of a
formula (soy isolates, casein and whey protein)
• Hydrolyzed protein - types of proteins are enzymatically broken down to
smaller particles and increase the osmolality of the formula
Vitamins and Minerals
• Vital components in enteral formula
• Formulas generally have 100% of the recommended dietary allowance (RDA)
of each vitamin and mineral at specific volumes
Fiber
• formulas that include fiber generally have about 4 to 14 g/L of total
fiber
• Soluble fiber - viscous and found in legumes, oat bran, pectins, and gums.
• maintain colonic structure and function.
• enhances fluid and electrolyte absorption
• lower serum cholesterol, as well as improved glucose tolerance.
• Insoluble fiber is nonviscous and found in the cellulose of plant foods.
• This increases bulk in fecal mass and allows softer stools
Pre- and Probiotics
• Promote gut health
• Prebiotics are energy sources for the beneficial bacteria in the colon,
commonly provided in EN formulas as fiber, fructo-oligosaccharides, and
inulin. Food sources include artichokes, banana, onions, garlic, and soy.
• Probiotics are ingested microorganisms thought to promote beneficial gut
microflora and gastrointestinal function, as well as compete against
pathogenic bacteria. A common form used in formula is lactic acid bacteria.
Disease- Specific
Formulas
Disease –Specific Formulas
• enteral formulas for patients with specific illnesses; also called
specialized formulas.
Renal Dysfunction
• formula that is more calorically dense and lower in phosphorus and potassium
than standard polymeric TFs.
• assure protein of high biological value to include proportionately more essential
amino acids.
• Patients who have stage 3 or 4 chronic kidney dis- ease and are not yet on dialysis
may need less protein in their formula
Pulmonary Dysfunction
• Have a modified carbohydrate-to-fat ratio to decrease carbohydrate
intake.
• Oxidation of carbohydrate results in greater carbon dioxide (CO ) 2
production than fat oxidation.
• Patients with Hypercapnia (CO2 retention)
• use of high-fat, low-carbohydrate TF in patients with chronic obstructive
pulmonary disease may improve pulmonary function.
Liver Dysfunction
• formulas for these patients are often calorically dense, providing a high
calorie-to-nitrogen ratio.
• Protein composition - higher proportion of branched chain amino acids
(BCAA) with lesser amounts of aromatic amino acids in attempt to
minimize hepatic encephalophathy (a condition that is associated with
liver disease).
Diabetes
• For better glycemic control, which are higher in fructose and
monounsaturated fatty acids.
• These formulas generally have a carbohydrate content of about 35% to
40% of calories, approximately 10 to 15 g/L of soluble fiber, and fat (40%-
50% of calories).
Trauma/ Wound Healing
• EN solutions that are high in protein and include arginine and glutamine,
as well as micronutrients zinc and vitamin C, should enhance the process
of wound healing due to their effects on protein anabolism (arginine and
glutamine) and collagen synthesis (zinc and vitamin C).
Developing an EN
Feeding Plan
Complication
Monitoring
Complication Monitoring
• Patients who are receiving TF must be monitored routinely, because
complications can arise.
• Check for signs of nausea and vomiting
• make note of the gastric residuals (volume of liquid that remains in stomach
during enteral feeding)
Aspiration
• common complication associated with tube feeding
• occurs when a patient inhales a substance, such as water or tube feed,
into the airway, which causes dyspnea and coughing.
• Prolonged aspiration is dangerous because it can lead to pneumonia.
Nausea/Vomiting
• increase the risk of aspiration and pneumonia
• must reduce the rate of feeding, but if the patient is vomiting, feedings
should be held.
• with feedings that are lower in fat being generally better tolerated. The
smell of the formula can affect the patient.
• Elemental formulas usually have a more unpleasant odor than polymeric formulas.
Abdominal Distention
• the accumulation of air or liquid in a patient’s abdomen and can cause
major discomfort to the patient.
• can also be caused by nutrient malabsorption, delayed gastric emptying,
or the onset of a septic episode
Gastroparesis (Delayed Gastric Emptying)
• can be induced by trauma or be caused by certain medications, such as
opiates or paralytics.
• to mitigate the risk of gastroparesis, a clinician may check gastric residual
volume (GRV) before initiating tube feeding, as well as every 4 hours after
tube feeding.
Gastroparesis (Delayed Gastric Emptying)
• Normal GRVs range from 250 to 500 mL. Anything greater than 600 mL
may indicate delayed gastric emptying, which puts a patient at risk for
aspiration.
• Continuous feeds may be preferred over intermittent or bolus feeds to
normalize gastric emptying.
Constipation
• Certain medications can cause constipation
• Dehydration and lack of fiber are also frequent causes
• Adding additional fluid to the formula in addition to fiber can pre- vent
waste buildup
Diarrhea
• is higher stool frequency, volume, and water content.
• Certain medications, especially those containing magnesium, phosphorus,
and sorbitol, can be hyperosmolar.
• Prolonged antibiotic use creates an imbalance in gut microflora, resulting
in antibiotic associated diarrhea.
• caused by aspects directly related to tube feeding. (rapid feed infusion,
hyperosmolar formula, carbohydrate malabsorption, or intolerance to
lactose in the formula.)
Southern Philippines Medical Center
Nutrition and Dietetics Service
PARENTERAL
NUTRITION SUPPORT
Insert
RONA CRISTY MATUNOG-RETULLA, RND
Clinical Dietitian
photo
Enteral Feeding Unit Supervisor
here
Cancer Institute
Learning Agenda
1. Brief History of Parenteral Nutrition
What we’ll 2. Parenteral Nutrition Administration
discuss today 3. Parenteral Nutrition Formulation
Parenteral Nutrition
Parenteral Nutrition (PN)
• a type of nutrition support that relies on the intravenous administration of nutrients
to patients who are unable or unwilling to take adequate nutrition orally or
enterally.
• used as;
• an addition to an oral diet or enteral nutrition (EN) in order to meet needs
• sole source of nutrition during recovery from illness or injury of the gastrointestinal (GI) tract
• as a long-term life-sustaining therapy for patients who have compromised ability to enterally
absorb nutrients.
Brief History of
Parenteral Nutrition
Parenteral Nutrition (PN)
• 17th century - intravenous nutrition has been of interest to the medical
and nutrition communities as a means to improve nutrition status
• 1960 – PN was successfully utilized in a human model
• The Pioneers - Dr. George Blackburn, Dr. Stanley Dudrick, Dr. Harry Vars, and Dr.
Douglas Wilmore, in treating PEM in patients who were either unable to use the
gastrointestinal tract or were experiencing failure to thrive despite sufficient oral
consumption.
Parenteral Nutrition (PN)
• Dudrick and his colleagues began their studies on the feasibility, efficacy,
and safety of parenteral nutrition with a laboratory study with six beagle
puppies and matched them in skeletal growth, development, and
activity .
Parenteral Nutrition (PN)
• There were no significant differences between growth rates or weight
gain between the experimental puppies.
• The success of the study prompted a clinical study in 30 human patients
with chronic complicated gastrointestinal disease.
• patients experienced improvements in wound healing, fistula closure, weight
gain, and strength and activity.
Parenteral Nutrition
Administration
Venous Access
• Central Parenteral Nutrition - venous access is acquired in a central
vessel, namely the superior or inferior vena cava or the right atrium.
• Peripheral Parenteral Nutrition - access is obtained in a peripheral
vessel, such as the vessels of the hand or forearm.
• access is obtained in a peripheral vessel, such as the vessels of the hand or
forearm.
• catheters, also known as vascular access devices (VADs)
Central Parenteral Nutrition
• the catheter tip is located in a large, high-flow vessel, typically the junction of the superior vena cava
and right atrium.
• the vena cava and right atrium are sites of high blood flow that can quickly disperse PN solutions
• Thrombophlebitis - or inflammation of a vein caused by a blood clot
• Extravasation - inadvertent administration or leakage of the PN into surrounding tissues instead
of a vein.
• The ideal tip location is the lower third of the superior vena cava or at the atriocaval
junction, as these locations are associated with the fewest mechanical and thrombotic
complications.
Central Parenteral Nutrition
• Two types of central access:
• Short-term central venous catheters (CVCs) - often referred to as non-tunneled
catheters, vary by insertion site and may be inserted in the subclavian, internal
or external jugular, or femoral veins.
• peripherally inserted central catheter (PICC) - CVCs may be inserted in the arm via the
cephalic or basilic vein.
• Long-term central venous catheters (CVCs) - referred to as tunneled catheters as
they are tunneled under the skin to the venous site although the catheter exits
through the
Central Parenteral Nutrition
Central PN is usually the preferred form of access because it allows greater
flexibility in the types of PN infusions that can be administered
• Characteristics of PN formulas that would necessitate central access
include the following:
• Hyperosmolarity (≥10% glucose or ≥5% amino acids, or 900
mOsm/L)7,8
• High (>9) or low (<5) pH7
• Infusions containing vesicant drugs (can cause the vessels to become
leaky)
Peripheral Parenteral Nutrition
• the catheter tip is located outside of a central vessel
• peripheral PN may be selected because it is a safer and easier way to access the
vasculature
• typically used for a maximum of 2 to 6 weeks at a time
• PN formula cannot be as hypertonic as those formulas used in central PN.
Formulas should be of low osmolarity, defined as <900 mOsm/L.
Indications and Contraindication
• When evaluating whether a patient is eligible for PN;
• consider that PN carries a high risk of serious complications. I
• it is also a costly therapy, due to the expense of vascular access
devices, monitoring laboratory values, and treating potential
complications
• should not be considered a first line of therapy in nutrition support
Indications and Contraindication
• The benefits of enteral feeding are significant and every attempt should be made to
trial enteral nutrition (EN) therapy before PN is considered.
• compared with PN, EN is associated with reduced risk of infection (e.g., pneumonia
and central catheter infections)
• reduced length of stay in intensive care unit (ICU) patients.
9
• EN promotes blood flow to the gut and the maintenance of tight junctions, thereby
preventing the gut from becoming leaky and reducing the risk of systemic infection
and stress ulcers.
Indications and Contraindication
• Determining whether a patient is a candidate for PN requires a
thorough nutrition assessment, the first step of the nutrition care
process (NCP). If a patient cannot meet their nutritional needs
through oral intake or EN alone, and is either at risk of malnutrition or
is already malnourished, they may be a candidate for PN.
Parenteral Nutrition
Formulation
Parenteral Nutrition Formulation
• Parenteral nutrition is a hypertonic
solution made up of, but not
limited to, carbohydrate in the form
of dextrose, crystalline amino acids,
lipid emulsions, vitamins, minerals,
and sterile water.
Carbohydrate
• The most commonly used carbohydrate substrate used in PN formulas
is dextrose monohydrate, the dextrorotatory form of glucose. In its
hydrated form, dextrose provides 3.4 kcal per gram, not 4 kcal per gram
like dietary carbohydrates.
• dextrose is available in multiple concentrations ranging from 5% to
70%.
• Dextrose infusion can be challenging due to its effect on blood sugar
Carbohydrate
• The most common dextrose solution used in parenteral nutrition
is 50% dextrose in water (D50W).
• This concentration supplies 500 grams of dextrose per liter and 1700 kcal
per liter
Carbohydrate
• In fluid-restricted patients, more concentrated PN is indicated.
A more-concentrated dextrose solution like D60W or D70W is
often used in compounding because less volume is required to
meet carbohydrate requirements.
Amino Acids
• Amino acids are supplied through PN in their crystalline form.
• If oxidized for energy, crystalline amino acids supply 4 kcal per gram.
• amino acid solutions are available in different concentrations ranging
from 3% to 20%.
• All commercially available amino acid solutions for PN contain all nine
essential amino acids in varying amounts between 38% and 57% of total
amino acids
Lipids
• The infusion of lipid injectable emulsions (ILEs) provides a high
energy supply, contributes to the prevention of high glucose
infusion rates, and is indispensable for supplying the body with
essential fatty acids (EFAs).
• In 2016, the Food and Drug Administration approved SMOFlipid, which is
comprised of four different oils: 30% soybean, 30% medium-chain
triglycerides derived from coconut oil, 25% olive oil, and 15% fish oil.
Lipids
• Most intravenous lipid emulsions contain egg yolk phospholipids as an
emulsifying agent and soybean oil as the primary lipid source. For this
reason, egg and soy allergies are contraindications of intravenous lipid
infusion.
Electrolytes
• therapeutic amounts of various electrolytes are added to PN
formulations depending on the patient’s individual requirements
• Acetate and chloride do not have specific ranges for intake; rather,
they are adjusted as needed to maintain acid– base balance.
Multivitamins
• patients receiving PN require vitamins to prevent deficiency
and promote optimal health.
• Commercially available vitamin products for parenteral nutrition
supplementation include both single and multivitamin infusion
products
Trace Elements
• patients receiving PN require vitamins to prevent deficiency
and promote optimal health.
• Commercially available vitamin products for parenteral nutrition
supplementation include both single and multivitamin infusion
products
"if the gut works, use it’’
“if the gut works partially,
use it partially’’ RONA CRISTY MATUNOG-RETULLA, RND
Clinical Dietitian
Enteral Feeding Supervisor
Cancer Institute
