II. 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

III. 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

IV. 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)

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Enteral Nutrition (C0014327)

Definition (MSH) Nutritional support given via the alimentary canal or any route connected to the gastrointestinal system (i.e., the enteral route). This includes oral feeding, sip feeding, and tube feeding using nasogastric, gastrostomy, and jejunostomy tubes.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D004750
English Enteral Nutrition, Nutrition, Enteral, EN - Enteral nutrition, tube feeding, enteral nutrition, nutrition enteral, Enteral nutrition
French Nutrition entérale
Swedish Sondmatning
Japanese ケイチョウエイヨウ, 経管栄養補給, 強制栄養, 高カロリー栄養法-経腸, 経腸栄養補給法, 栄養補給法-経腸, 経管栄養, 経腸高カロリー栄養法, 経腸栄養, 栄養-経腸
Czech enterální výživa, Enterální výživa
Finnish Enteraalinen ravitsemus
Italian Nutrizione enterale, Alimentazione enterale
Polish Żywienie przez zgłębnik, Żywienie dojelitowe, Żywienie dożołądkowe
Hungarian Enterális táplálás
Norwegian Enteral ernæring, Sondeernæring
Portuguese Nutrição entérica, Nutrição Enteral
Spanish Nutrición enteral, Nutrición Enteral
Dutch enterale voeding, Nutritie, enterale, Voeding, enterale
German enterale Ernaehrung, Enterale Ernährung, Ernährung, enterale

Ontology: Dietary Supplementation (C0242297)

Definition (NCI_NCI-GLOSS) Adding nutrients to the diet.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D019587
English Supplementations, Dietary, dietary supplementation, Supplementation, Nutritional Supplementation, Nutritional supplementation, Nutritional supplement, supplementation, Dietary Supplementations, Dietary Supplementation, nutritional supplementation
Portuguese Suplementação Dietética, Suplementação nutricional, Suplemento nutricional
Spanish Suplementación Dietética, Aportación nutricional suplementaria, Suplemento nutricional
German Nahrungsergänzung, Nahrungsergaenzung, Nahrungsergaenzungsmittel
French Supplémentation nutritionnelle, Supplément nutritionnel, Supplément nutritif
Czech dietní suplementace, doplňování stravy o chybějící mikroelementy, Nutriční suplementace, Nutriční doplněk
Dutch aanvulling met voedingssupplementen, voedingssupplement
Hungarian Táplálékkiegészítés, Táplálékkiegészítő
Italian Integratori alimentari, Supplemento nutrizionale
Japanese 栄養補給, エイヨウホキュウ, エイヨウホジョ, 栄養補助