Enteral Nutrition During Deployment

1. Enteral Nutrition During Deployment JENNIFER GRAF, MS, RD LIEUTENANT COMMANDER, USPHS NUTRITION DEPARTMENT NATIONAL INSTITUTES OF HEALTH JUNE 21, 2012

2. Disclaimers Brand name formulas are included for purposes of education and their inclusion does not reflect bias or endorsement of a particular product or brand. Suggestions for short-term solutions when specialized formulas are not available are often based on my personal judgment rather than evidence. I hope to discuss others’ suggestions as well.

3. Outline of Talk • Set the scene for deployment • Review enteral nutrition guidelines in the context of deployment • Assess the need for specialized formulas in various disease conditions • Walk through case studies

4. Subject Matter Experts • Ship Deployment • CDR Kathleen Edelman • CDR Pamella Vodicka • Federal Medical Station (FMS) • CDR Blakeley Fitzpatrick • LCDR Merel Kozlosky • Coppola, Dean, CAPT, USPHS. “Leadership of a Federal Medical Station-Special Needs Shelter” slide presentation

5. Ship Deployments Challenges to Optimal Care • Space is limited for supplies and staff • Replenishment of supplies can be delayed • Must keep close tabs on supply and par level • Specialty items require much coordination • Limited phone/email access • NJ tube feed placement may be appropriate given seasickness • Must prioritize time and demand on others • Plans/recommendations must be simple

6. CDR Vodicka meeting with an enterally fed patient in Trinidad

7. Reed Arena, College Station, TXHurricane Ike

9. Special Needs Patient • Any individual who would need assistance to evacuate and shelter due to physical or mental disabilities and/or someone who requires the level of care and resources beyond the care available in a general population shelter, yet does not require hospitalization. • Examples: behavioral health, hospice, morbid obesity, diabetes, respiratory disease, hypertension, orthopedic, gastrointestinal disease Taken from: Coppola, Dean, CAPT, USPHS. “Leadership of a Federal Medical Station-Special Needs Shelter” slide presentation.

10. FMS- Hurricane Ike, College Station, TX 2008 Special Needs Category (9/16/08) 0 7% 1 16% 2 12% 3 24% 4 26%*** 5 15%*** Provided courtesy of CAPT Dean Coppola

11. Hurricanes Rita, Gustav, and Ike Types of Patients Seen • Chronic diseases • Renal disease • Diabetes Mellitus • Degenerative neurologic disorder with dysphagia • Nursing home residents • Higher acuity • Burn patients on TPN/TF (accompanied by nurses and supplies) • Ventilated patient s/p GSW on TF (brought own formula) • Tube feeding patients • Usually came with some formula supply, but often no instructions

12. Hurricanes Rita, Gustav, and Ike Supplies in FMS Cache • Formulary of enteral formulas (not official list?) • Enfacare, liquid • Milk-based Infant formula, liquid • Soy-based infant formula, liquid • Vanilla supplement, powdered • Diabetic formula, powdered • Oral rehydration packets • Tube feeding kits • May not be fully stocked or substitutions may be made

13. Hurricanes Rita, Gustav, and Ike (cont.) Other Challenges • At initial set up, may not have potable water or food • Lab values, weights, fluid balance not readily available • Medical history may be incomplete

14. Dietitians’ Other Responsibilities • Securing food and potable water • Screening over 200 patients • Dysphagia, NPO, special diets • Plating/serving food • Maintaining food par levels • Cleaning

15. Priorities at Arrival to FMS • Assess formulas and supplies in FMS cache • Identify a local facility (university, hospital, retail store) that could be a source of specialized or additional formula • Coordinate a contract through the Logistics Team • Assess special formula needs • Become familiar with process of pharmacy orders to IRCT • Identify how tube feeding orders are being communicated • Recommend patient transfer if unable to safely meet needs **Be flexible and make do with what you have while taking the route of least harm to the patient**

16. Resources to Bring • Food and Nutrition Guide for Deployment • AND Nutrition Care Manual • Pocket product guides for Abbott, Nestle, Nutricia • American Association of Kidney Patients Nutrition Counter http://www.aakp.org/userfiles/File/NutritionCounter_English(9).pdf • If deployed to relieve rapid deployment group, contact dietitians at FMS to find out what resources may be necessary.

17. Work-up for Enteral Feeding

18. Identify Who Should Receive Enteral Feeds • Oral intake is inadequate • Poor appetite • Very high needs (trauma, burns, wounds, critical illness, catch-up growth) • Oral intake is impossible • Structural barriers (e.g. tumor, esophageal atresia) • Oral intake is unsafe • Impaired swallowing function (neuromuscular disease) • Risk for aspiration AND… GI tract is functional

19. Absolute Contraindications for Enteral Feeding • Hypovolemia/Hypotension (poor gut perfusion) • Never feed until fluid resuscitated and hemodynamically stable • Bowel obstruction • Intractable vomiting • Upper GI bleeding • High output GI fistulas

20. Site of Enteral Access • Nasal tubes • Endoscopically placed ostomy tubes • Gastric • Functional stomach • Absence of significant delayed gastric emptying, vomiting, aspiration • Post-pyloric • Gastric outlet obstruction • Gastroparesis • Pancreatitis- Place past Ligament of Treitz • Reflux/risk for aspiration- Place past Ligament of Treitz?

21. Estimate Needs(refer to deployment guide) • Predictive equations are weight-based • Energy needs • Use ideal body weight if underweight or poor growth • Better to under-estimate needs initially and adjust per hunger or wt • Protein needs • Higher for critically ill • Fluid needs • Increased with hot conditions, fever, losses (diarrhea, fistula) • If no weight available • Ask the patient • Use reference weights for age and adjust

22. Recommend Feeding Schedule • Bolus-delivered by gravity via a syringe • More physiologic • Low concern for gastric delay or aspiration • Continuous-delivered using enteral pump at a specified rate for extended period of time • Presence of delayed gastric emptying, reflux, dumping syndrome • Suspected risk for refeeding syndrome • Overnight feeds • Small bowel feeds

23. Select a Formula • Patient-related factors • Nutrient requirements • Electrolyte balance • Digestive/absorptive capacity • Disease state • Renal function • Food allergies • Formula-related factors • Digestibility of nutrients • Nutrient adequacy • Osmolality • Viscosity • Ease of Use

24. Final Considerations Before Starting Feeds • Be sure patient is hemodynamically stable and volume replete • Replete electrolytes if at risk for refeeding • Start/advance feeds extra slowly using isotonic formula for: • Critically Ill • Undernourished • Those who have not been enterally fed for an extended period of time • Do not use formulas that contain fiber or arginine for critically ill • Provide adequate free water • Consider all sources: IV’s, water in formula, and flushes • May require extra water boluses.

25. Initiate Feeds • Start formula full strength • Adults: See page 21 of Deployment Guide • Children • Bolus • 25% needs or 2.5-5 ml/kg divided among 6-8 boluses over >15-20 minutes • Advance by 25% per day until reach goal • Condense to 4-6 boluses per day as tolerated • Continuous • 1-2 ml/kg/hr (1 ml/kg/hr for kids >35 kg) • Advance 0.5-1 ml/kg/hr every 6-24 hrs

26. Monitor Patient • Weight • Fluid status (Ins/Outs) • Labs: electrolytes, glucose • Actual delivery of formula • GI symptoms • Reports of hunger/thirst from patient • Gastric Residual Volumes • Controversial

29. Minimize Bacterial Contamination • Formula Preparation • Powdered formulas are not sterile; use ready-to feeds (RTF) if available • Clean RTF can lids • Keep opened RTF formula covered in refrigerator ; expires in 24 hr • Prepare formulas in disinfected, separate area with little traffic, no cleaning supplies and without strong air currents using disposable or heat-sterilized equipment (dishwasher to 180 degrees) • Use chilled, sterile water (can boil 1-2 minutes & cool) • Use whisk (not blender) • Powdered formula cans: once opened, keep lidded in clean, cool, dry place; expires in 1 month • Prepared formula: keep in sealed container in fridge; expires in 24 hr • Formula Hang times- 4 hr

30. Maintain Quality Control • Formula preparation • Measure powders by weight • May need to use scoop provided in can if no scale available • Verify formulations for accuracy and appropriateness • Labeling of prepared formulas • Patient identifiers • Formula name, concentration, volume • Expiration date and time • Check label against the order

31. Do you really need a specialized formula? What if you do not have one available?

32. Standard Polymeric Formulas

33. Standard Formula • Polymeric formula – intact protein • Energy Density • Infant formulas- 20 kcal/oz • Pediatric/Adult formula- 30 kcal/oz • Micronutrients • Needs generally met by 1-1.5 L of formula • Water • ~80-85% free water

34. Renal Formulas • Varying amounts of protein • Lower/Absent Electrolytes (Na, Ca, K, Mg, Phos) • Fluid restricted (1.8-2 kcal/ml)

35. Renal Disease • Considerations: • Stage of disease and access to dialysis • Access to sodium polystyrene sulfonate • Acute Risks: • Heart arrhythmias from high potassium (K) • Pulmonary edema or congestive heart failure from excessive fluid • Acute event from hypertension • Possible short-term substitute for renal formula: • ?May not be able to tolerate any volume (no formula) • ?Standard formula at a reduced volume to limit Na, K and fluid • Make up calories and protein with K-free modulars • Always discuss your plan with medical team! • Conditions may be much more complex than perceived

36. Hepatic Disease • BCAA-enriched formulas not indicated • Specialized formula not indicated

37. Formulas for Diabetes • Lower % CHO (~35% of kcal) • Higher % Fat • Complex carbohydrates (including more fiber)

38. Diabetes • Acute Risk: Hyperglycemia/Increased Infection Risk • Short-term substitute for diabetes formula: • ?Standard formula at appropriate kcal level • Communicate with physicians and nurses about frequent blood glucose checks and insulin coverage

39. Pulmonary Disease • Chronic Obstructive Pulmonary Disease • Risk: Overfeeding leads to increased CO2 production • Specialized formula not indicated • Do not provide excess kcal

40. Free Amino Acid Formulas Used for Allergies or Severely Impaired GI Function for Infants, Older Children and Adults

41. Allergy • Considerations • Be sure that lactose intolerance is not being confused for milk protein allergy • Most formulas are lactose-free, gluten-free • Risk: Anaphylaxis • Goal: To obtain a formula free of allergen • Safest choice for milk or soy allergies or multiple protein allergies is free amino acid formula

42. Peptide-based with MCT oil • Often selected in cases of malabsorption • Partially hydrolyzed protein • Higher % MCT oil

43. Impaired GI tract/Malabsorption • Considerations: • Degree of GI impairment • Access to pancreatic enzymes if needed • Acute Risk: Increased stool output/dehydration • Short-term substitution: • ?Standard formula run continuously at slow rate with consideration of fluid and potassium losses • If severe GI impairment, may need supplemental TPN if using standard formula

44. Wounds • Ensure adequate kcal, protein and vitamin/mineral status (especially Vitamins A,C,E, and Zinc) • Specialized formula not indicated

45. Pediatric (>1 yr old) • Considerations: • Adult formulas often contain higher levels of the following: • Protein- risk for dehydration • Vitamin A • Iron • Electrolytes (Na, K) • Magnesium • Folic Acid • Zinc • Acute Risk: Dehydration; consider extra fluid for high protein (see deployment guide p. 6) • Note: concentrated infant formula (30 kcal/oz) may also be appropriate for toddlers

46. Modulars • Extra calories • Vegetable oil- monitor for separation; consider giving as bolus • Cornstarch • Extra protein • Powdered milk- be sure to mix very well to avoid clogging tube • Pasteurized egg whites

47. Case Study 1 • 57 yr old male with chronic renal disease • Accompanied by his wife who is a better historian • Has a history of poor intake and has G-tube • Receives bolus of 1 can Nepro, 2-3 x/day + oral snacks • Usually gets hemodialysis M/W/F, but missed Fri (now Mon) • Pt has small amount of urine output still • Has not gotten tube feeds in 5 days; eating potato chips, granola bars- made him thirsty to drinking 1-2 20 oz water bottles/day • Social worker trying to arrange dialysis for tomorrow • No labs available • O2 saturations are low 90’s • FMS cache has Glucerna and Ensure available

48. Case 1 • What are the major considerations? • Pt has been having minimal intake for 5 days • Potassium likely elevated • Fluid overload • Dangerously high blood pressure? • What do you recommend right now? • No more fluid until dialysis • Consumption of only low Na and low K foods • Initiate a plan to obtain a renal formula comparable to Nepro • Discuss plan with physician

49. Case 1 • Later that week, patient is able to start regular dialysis • What are new recommendations? • Liberalize fluid and electrolyte intake somewhat, but continue to limit them • Try to provide adequate kcal and protein • Implementation • Provide standard formula in amount that would provide similar potassium as 3 cans of Nepro (his usual intake while on dialysis) • Depending on oral intake, could add vegetable oil to meet kcal goal. Skim milk powder contains K so would not be a good way to meet protein goal. • Explain/discuss rationale of plan with physician

50. Case Study 2 • 5 yr old female with baseline neurologic impairment • Per mother • Wt= 34 lb (15.4 kg) • Usually gets continuous feeds of Pediasure at 45 ml/hr x 22 hr via G-tube; never eats by mouth • Has been growing well on this regiment • Mother brought Pediasure from home, but it went missing at last shelter • FMS cache has only powdered infant formula or RTF Boost