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
- Short-term: Nasogastric, Nasoduodenal, Nasojejunal
Gastrostomy & Jejunostomy (surgically placed) and PEG - percutaneous-esophago-gastrostomy & PEJ - percutaneous-esophago-jejunostomy (endoscopically placed)
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
||Similar to average diet||Normal digestion|
|High nitrogen||Protein>15% of total kcal||
|Caloric dense||2 kcal/ml||
||Fiber 5-15 g/L||Regulation of bowel function|
One or more nutrients are hydrolyzed.
|Impaired digestive and absorptive capacity|
|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|
||Higher % of calories from fat instead of carbohydrates||ARDS|
|Diabetic||Low carbohydrates||Diabetes mellitus|
|Immune-enhancing||Arginine, glutamine, omega-3 fatty acid, antioxidants||
from http://www.rxkinetics.com/tpntutorial/2_1.html (Note: N170 students responsible for Nutritional concepts and Enteral Nutrition ONLY)
6. Administration of feedings
||Highest risk of aspiration, N/V, abdominal pain and distention, and diarrhea|
7. Feedings started:
- In the past tube feedings that were hyperosmolar were diluted Â½ 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
- Check gastric residuals
- Bloating and excess gas production
- 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 30Â° at all times.