Enteral nutrition - Modes, Indications, Complications

Enteral nutrition - Modes, Indications, Complications

1. ENTERAL NUTRITION

2.  5-7 days of inadequate intake  Expected no intake for 7-9 days  Prolonged anorexia  Inability to take oral feedings  Impaired intestinal function  Critical illnesses INDICATIONS:

3.  Intestinal Obstruction  Intestinal Ischaemia/Perforation  Inability to access the gut.  Severe acute pancreatitis  High output proximal fistula  Shock CONTRAINDICATIONS :

4.  Preserves gut integrity  Possibly decreases bacterial translocation  Preserves immunological function of gut  Better tolerated by patient  Less costly than TPN ADVANTAGES

5.  Oral dietary supplements  Polymeric feeds  Monomeric  Specialized diets  Disease-specific feeds TYPES

6.  Gastric  Postpyloric ADMINISTRATION SITES :

7. Advantages  More Physiological  Ease of placement  Formula osmolarity less problem Disadvantages  Delayed gastric emptying  Gastroesophageal reflux and aspiration GASTRIC FEEDS

8. Advantages  Minimize aspiration risk Disadvantages  Difficulty with placement  Feeding intolerance POST PYLORIC FEED

9.  Nasogastric  Nasojejunal  Percutaneous endoscopic gastrostomy  Open gastrostomy  Transgastric jejunostomy  Jejunostomy TYPES OF FEEDING TUBES

10.  If tube feeding is needed for ≤ 4 to 6 weeks, nasogastric or nasoenteric is usually used.  Tube feeding for > 4 to 6 weeks usually requires a gastrostomy or jejunostomy tube.

11.  Cheap  Easy to insert  Residual volume can be assessed  Uncomfortable  Easily dislodged  Increase aspiration risk NASOGASTRIC TUBE Disadvantages

12.  Decreased risk of aspiration  Decreased stimulus to pancreatic secretion  Indicated--gastric reflux --delayed gastric emptying Disadvantages  Not easy to place  Damage to gastric mucosa  Impaired absorbtion NASOJEJUNAL TUBE

13. Placement of tube through abdominal wall directly into stomach. GASTROSTOMY TUBE

14. Nowadays performed by percutaneous insertion under endoscopic control known as PEG.

15. o Contraindications o Gastric ulcer o Gastric carcinoma o Ascites o Coagulation disorders

16.  Complications  Sepsis around PEG site  Nectrotizing fascitis and intraabdominal wall abscess  Persistent gastric fistula

17. Creation of opening through skin at front of abdomen and jejunal wall. JEJUNOSTOMY

18.  Percutaneous Endoscopic jejunostomy  Technically difficult  Allows concomittent jejunal feeding and gastric decompression.

19.  Bolus  Continuous  Intermittent  Cyclic ADMINISTRATION

20. Bolus feeding Large amount (300-400ml) is given in short time period several times daily

21. Continous feeding Administration into the GIT via pump or gravity, usually over 8 to 24 hours per day

22. Intermittent feeding 300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe.

23. Cyclic via pump usually at night

24. Rate of administration  Gastric feeding  Standard formula : 50 cc/hr  Advanced by 25cc/hr every 4-8 hours until goal rate is made  Elemental formula :25cc/hr for first 12 hour  Advanced by 25cc/hr every 6-12 hour FEEDING PROTOCOL

25. Jejunal or duodenal feedings  Standard or elemental feeding at full strength at 25 cc/hr for first 12 hour then advanced by 25cc/hr every 6-12 hours.  Bolus feeding method not used.

26. Gastric feeds  Check residual volumes every 4 hours  Hold tube feeding residual greater than 200cc  Reinfuse residual recheck in 2 hours  Feeds should be held if increasing abdominal distention MONITORING TOLERANCE

27. Jejunal feeds  Monitor abdomen for distension  bowel sounds every 4 hours  Residual volumes are not helpful  Hold feeds if emesis abdominal pain or distension

28.  Weight -- 3 times/week  Edema -- daily  dehydration -- Daily  Fluid intake--Daily  Nitrogen balance – 2times /week  Electrolytes  BUN, Creatinine-- weekly  Glucose, Ca ++, Mg++ -- weekly  Stool output-- Daily MONITORING

29.  Tube related  Malposition  Displacement  Blockage  Breakage/leakage  Local complication ( erosion of skin / mucosa ) COMPLICATIONS

30.  Gastrointestinal  Diarrhea (most common an dperticularly common in critically ill  Bloating nausea vomiting  Abdominal cramps  Aspiration  Constipation

31.  Metabolic  Refeeding syndrome  Electrolyte disorder  Vitamin mineral trace element deficiencies

32.  Infective  Exogenous (handling contamination)  Endogenous (patient)

33. Thank you…