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Enteral Formulas and Tube Feedings

- See:
    - Composition
    - Lab tests; (same as TPN)

- Discussion:
    - elemental diets are most indicated in patients with severe mucosal disease (Inflammatory Bowel disease), short bowel syndrome, proximal pancreatic fistula, pancreatic insufficiency;
    - enteral nutrition is not safer than TPN - because of aspiration pneumonia;
    - controversies: should patients with dementia receive enteral support?
            - in review article by Gillick MR (2000), the author points out that there is little or no evidence to support the notion that enteral nutrition objectively or subjectively morbidity in the demented population;
                    - Rethinking the Role of Tube Feeding in Patients with Advanced Dementia.

- Orders for Feeding:
    - hence, when infusing into the stomach, sit the patient up at 30 deg and turn off the parental nutrition at 11:00 pm and only resume at 7:00 am - when the full nursing crew is present;
           - sudden changes in gut motility overnight due to sepsis may lead to filling of the stomach, lack of emptying, and aspiration;
    - may consider small bolus feeding (300 cc/3hr) because patient will miss feedings due to x-rays, physical therapy, etc
           - bolus feeding is in general to be avoided in acutely ill patients because of the risk of aspiration;
           - relative high fat content of these diets may cause a delay in gastric emptying, and patients should be checked for gastric residual, particularly during the fist 2 to 3 days of feeding;
    - start slowing at 20 ml per hour at the manufacturer's standard concen- tration and increase the amount by 20 ml per hour each day until 80 ml/hr (1920 kcal) to 100 ml/hr (2400 kcal) is well tolerated;
    - initial feedings should be 1/2 the final rate:
    - initially all feedings should be Isoosmolar; hypertonic feeds need to be diluted;
    - gastric feeding: first advance by concentration of formula;
           - then once the hyperosm feedings are tolerated at full strength, rate may be increased. bolus feeds may be used;
    - intestinal feeds: increase rate first, then the concentration;
           - osmolarity > 400 may not be tolerated; Do not bolus feed;
    - most feeds can be started at 40 cc/hr and advanced by 20 cc/hr increments q12hr as tolerated;
    - if feedings are stopped, must be flushed to prevent clogging;
    - if question the position of the tube, confirm radiographically;
    - elevate the Head of the Bed (30 deg) and check gastric residuals (should be < 100 cc q4hr);
    - consider reglan 10 mg IV/PO q6hr;

- Types of Feedings:
    - stomach is the only defense the body has against hyperosmolar feedings;
    - when hyperosmolar bolus is given, gastric motility stops & secretion of hypotonic solution into the stomach occurs until such time as iso-osmolarity is achieved;
    - at this point, gastric motility returns and the transfer of 2-4 cc across the pylorus every 30 sec. then occurs;
    - if hyperosmolar infusion is carried out to rapidly, diarrhea will result in dehydration, hyponatremia, and at times hyperosmolar non ketotic coma

Feeding jejunostomy in patients who are critically ill.

Early enteral feeding does not attenuate metabolic response after blunt trauma.

Improvement in immune function in ICU patients by enteral nutrition supplemented with arginine, RNA, and menhaden oil is independent of nitrogen balance.

Enteral nutrition in hypermetabolic surgical patients.

Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma.

Glutamine-enriched intravenous feedings attenuate extracellular fluid expansion after a standard stress.

Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study.

Enteral nutrition in the early postop period: a new semi-elemental formula versus total parenteral nutrition.

Enteral nutrition with supplemental arginine, RNA, and omega-3 fatty acids in patients after operation: immunologic, metabolic, and clinical outcome.

Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis.

Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team

Enteral feeding in sepsis: a prospective, randomized, double-blind trial.

Branched chain metabolic support. A prospective, randomized, double-blind trial in surgical stress.

Improved wound healing response in surgical patients receiving intravenous nutrition.

Impaired wound healing in surgical patients with varying degrees of malnutrition.

Beneficial effects of aggressive protein feeding in severely burned children.

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