Enteral Nutrition


Enteral Nutrition, Nutritional Supplement, Dietary Supplementation

  • Preparations
  1. Polymeric - Standard
    1. Isotonic, lactose-free, nutritionally complete formulas
    2. Indicated for normal gastrointestinal tract
    3. Adult: 1-1.2 kcal/ml
      1. Boost, Ensure, Isocal, Jevity 1.2, Nutren 1.0, Osmolite
    4. Child: 1 kcal/ml or 30 kcal/oz
      1. Boost kid essentials, Pediasure, Nutren Junior
  2. Polymeric - High Calorie
    1. Concentrated formulas with significantly higher calories per ml (typically by increasing fat concentration)
    2. Indicated for fluid restriction (CHF, SIADH) or high calorie requirement (e.g. Trauma)
    3. Adult: 2 kcal/ml
      1. Deliver 2.0, Novasource 2.0, Nutren 2.0, Twocal HN
    4. Child: 1.5 kcal/ml or 45 kcal/oz
      1. Boost kid essentials 1.5, Resource Just for Kids 1.5
  3. Polymeric - High Protein
    1. Indicated for hypercatabolic state or high protein requirement (e.g. Wound Healing)
    2. Adult: 1-1.5 kcal/ml with protein comprising 18-25% of total calories
      1. Boost high protein, Ensure plus HN, Isocal HN, Isosource HN, Osolite 1.2 CAL, Replete, Sustacal HC
  4. Polymeric - With fiber
    1. Isotonic, typically soy-based fiber of both soluble and insoluble types with 4-22 grams fiber per Liter
    2. Indicated for prevention of Diarrhea in the short-term, and Constipation in the long-term
    3. Adult: Ensure with fiber, Fibersource HN, Jevity, Ultracal
    4. Child: Nutren Junior with fiber, Pediasure with fiber
  5. Oligomeric
    1. Elemental formula, proteins with short peptides and free amino acids, higher osmolarity and lactose-free; 1-1.5 kcals/ml
    2. Indicated for malabsorption syndromes and pancreatic insufficiency
    3. Disadvantages: Expensive, may worsen Diarrhea
    4. Adults: Criticare HN, Peptamen, Perative, Subdue, Tolarex, Vital HN, Vivonex TEN, Vivonex Plus
    5. Child: Peptamen Junior, Vivonex Pediatric
  6. Diabetic Formulation
    1. Lower carbohydrate, higher monounsaturated fat, and higher fiber; 1 kcal/ml
    2. Preparations: Choice DM, Diabetisource, Glucerna, Glytrol
  7. Immunomodulating Formulation
    1. Higher protein, with increased arginine, glutamine, Omega-3 Fatty Acids and other components thought to improve immune response
    2. Indicated in ICU patients with major Trauma, burns, or the critically ill on Mechanical Ventilation
    3. Deliver 1-1.5 kcal/ml
    4. Preparations: Alitraq, Crucial, Impact
  8. Modular Formulation
    1. Indicated for a specific nutrient deficiency or as a component in a multi-formulation plan
    2. Protein formulations: Beneprotein instant protein powder, Promod
    3. Carbohydrate formulations: Moducal, Polycose
    4. Fat formulations: MCT Oil, Microlipid
    5. Fiber formulations: Benefiber
  9. Pulmonary Formulation
    1. Low carbohydrate, high fat, no fiber formulations with 1.5 kcal/ml
      1. Some contain Omega-3 Fatty Acids and antioxidants which may be considered in Acute Lung Injury or ARDS
    2. Indicated for COPD, Mechanical Ventilation weaning (formulated to reduce carbon dioxide production)
    3. Preparations: Nutren, Nutrivent, Oxepa, Pulmocare
  10. Renal Formulation
    1. Formulations with reduced Potassium, Phosphorus and Magnesium; available in low and high protein formulations
    2. High protein formulation (for renal replacement therapy): Magnacal Renal, Nepro
    3. Low protein formulation (if not ion Dialysis): Novasource Renal, Renalcal, Suplena
  • Labs
  1. Baseline
    1. Complete Blood Count
    2. Glucose
    3. Electrolytes including Magnesium, phosphate, Calcium
    4. Renal Function tests
    5. Liver Function Tests including albumin
    6. Serum Iron
    7. Vitamin B12
    8. Vitamin D
    9. Zinc
    10. Copper
    11. Serum Folate
    12. INR
  2. Monitoring: Frequency based on clinical status
    1. Complete Blood Count
    2. Glucose (several times daily)
    3. Electrolytes including Magnesium, phosphate, Calcium
    4. Renal Function tests
    5. Liver Function Tests including albumin
      1. Expect 2-3 fold over baseline with 10-14 days TPN
  3. Monitoring: periodic recheck when on longterm Enteral Nutrition
    1. Vitamin B12
    2. Vitamin D
    3. Zinc
    4. Copper
    5. Serum Folate
  • Complications
  1. Aspiration Pneumonia (up to 44% of cases)
    1. Elevate head of bed to 30 degrees
    2. Measure gastric residuals periodically and adjust instillation volumes as needed
    3. Inflate endotracheal cuff if intubated
    4. Consider postpyloric feeding (Nasoduodenal tube or Jejunostomy)
  2. Diarrhea (up to 65% of cases)
    1. Management
      1. Evaluate for and treat underlying cause first
      2. Reduce rate and titrate more slowly
      3. Add fiber to formulation
      4. Consider antidiarrheal medication
    2. Causes
      1. Sorbitol containing elixirs
      2. Antibiotics with secondary Clostridium difficile
      3. Low fiber content
      4. High fat content
      5. Bacterial contamination of delivery device
      6. Hyperosmolar formulation
      7. Delivery rate too high
  3. Feeding Tube related complications
    1. See Feeding Tube
  4. Fluid, Electrolyte, and metabolic abnormalities
    1. Hyperglycemia
    2. Vitamin K Deficiency
    3. Trace element deficiency (zinc, copper)
    4. Vitamin B12 Deficiency
    5. Iron Deficiency
    6. Hypertonic Dehydration (calorie dense formulations with inadequate fluid intake)