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Adult Enteral Nutrition Deciphering the Code

Adult Enteral Nutrition Deciphering the Code. Mark H. DeLegge, MD, FACG, AGAF, FASGE Digestive Disease Center Charleston, SC. Indications for EN. “If the gut works…use it” EN is the preferred route of nutrition when oral intake is inadequate or a patient is unable to eat. What Do We Infuse?.

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Adult Enteral Nutrition Deciphering the Code

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  1. Adult Enteral NutritionDeciphering the Code Mark H. DeLegge, MD, FACG, AGAF, FASGE Digestive Disease Center Charleston, SC

  2. Indications for EN • “If the gut works…use it” • EN is the preferred route of nutrition when oral intake is inadequate or a patient is unable to eat.

  3. What Do We Infuse?

  4. Formula Selection • Assess digestive and absorptive capacity and GI tolerance • Determine kcal, protein, fluid, vitamin and mineral requirements • Determine if there are any mineral or electrolyte restrictions • Assess indication for specialty formula • Identify tube of type and infusion method

  5. What’s the Situation • 65 y/o F s/p CVA • NG tube for feeding • Weight: 60 kg • Est kcal needs: 1500kcal/day (25 kcal/kg/day) • Est protein needs: 60 gram/d (1 gm/kg) • Normal gastrointestinal function • No mineral or electrolyte restrictions • Renal disease

  6. Tube Feeding Formulas • *Blenderized (Table food) • Standard isotonic (Most common) • HN - High nitrogen • Nutrient dense • Fiber-containing • Hydrolyzed • Specialty

  7. In Our Patient • Normal GI function • No need for high protein diet • No evidence of renal failure, uncontrolled diabetes • No requirement of “high-tech” specialty formula • 1500 kcal/24 hours = 60 cc/hr

  8. Blenderized Product • Essentially blenderized table food • 1 calorie/cc • 85.4% water • Osmolality: 340 mosmo • Lactose-free • Moderately expensive • Compleat-B

  9. Standard Enteral Products • Low residue • 1 cal/cc • 300 mOsmo • Lactose-free • Inexpensive, moderately palatable • Casein protein - biological value lower than other sources of protein

  10. Nutrient Dense Formulas • Low residue • Functional GI tract required • Lactose-free • Inexpensive, moderately palatable • Casein protein • Fluid restricted patients • Renal compromised patients • Nutren 2.0, Magnacal, Jevity 1.5

  11. High Nitrogen Products • Low residue • Functional GI tract required • Lactose-free • Inexpensive, moderately palatable • Casein protein, higher concentration • Patients with wound healing, post-surgical, trauma, sepsis • Example: Replete, Osmolite HN

  12. Peptide-Based Formulas • Protein source: short peptides +/- free AAs • In times of stress small bowel mucosa ability to absorb short peptides increases • Altered GI tract absorption • Critical care • Inflammatory bowel disease • More expensive than standards • Example; Peptamen, Perative

  13. Dipeptides, Tripeptides, Short Peptides • Small intestine absorption (PepT1) • Fasting: increase in small intestine (PepT1) and (PepT1MRNA) at the small bowel mucosa (peptides 6-100 in length) • Inflammatory gut conditions – increase in small intestine (PepT1) production • Ogihara et al; Histochem J, 1999

  14. Elemental Formulas • Macronutrients in most elemental form • Protein: Free AAs • Fat: MCT, long-chain fats • CHO: glucose polymers • Expensive, unpalatable, High osmolality • Example: Crucial, Vital HN, Vivonex

  15. Our Patient • 1500 kcal, 60 gm protein, 1800 cc H20 • Standard: • 1.5 liters (1500 kcal) • 66 gm protein • 1270 cc/H20 • Nutrient dense (2 cal/ cc) • 750 cc • 63 gm protein • 462 cc H20

  16. Specialty Additives

  17. Immune Enhancing Formula

  18. Immune Modulating Ingredients • Definition • L-Arginine • Glutamine • Dietary Nucleotides • N-3 Fatty Acids

  19. Immune Modulating Nutrition: Meta-Analysis

  20. Consensus RecommendationsAppropriate Patient Populations • Patients undergoing elective GI surgery: Greatest benefit in malnourished • Trauma patients with ISS  18 or ATI  20 • Needs further study • Patients with severe sepsis • Other patients that may benefit: • Ventilator dependent • Elective surgery (prolonged need for ventilator, cancer with malnutrition) • Severe head injury • Burns  30% (third degree) • Head and neck cancer

  21. Omega-3 series Vasodilatory Anti-inflammatory Anti-aggregatory Immunostimulant Anti-arrhythmic Omega-6 series Vasoconstrictive Pro-inflammatory Pro-aggregatory Immunosuppressive Pro-arrhythmic Metabolic Effects of Lipids

  22. Enteral FormulationsMedium Chain Triglycerides • Easier absorption • Less pancreatic stimulation • Less immune suppressing

  23. Medium Chain Triglycerides • 24 HIV + patients with malabsorptive disease • LCT vs MCT enriched oral formulas • 3 day 100 gm fat diet, then trial diet 3 days • Craig et al; JADA, 1997 Gm/Day LCT

  24. Types of Feeding Administration • Continuous- given over 24 hours • Bolus - syringe feedings given every few hours (e.g. 240cc every 4 hours) • Nocturnal- TF given over 8-12 hours at night while patient is sleeping

  25. ConclusionKnow the code • Assess GI tolerance • Determine calorie, water, protein needs • Evaluate co-morbidities • Determine any special needs • Determine infusion method • Write the nutrition prescription

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