NUTRISI ENTERAL

Dept.Dept. Anestesiologi & Terapi Intensif Anestesiologi & Terapi Intensif FK-USU/RSUP H.Adam Malik- MedanFK-USU/RSUP H.Adam Malik- Medan

Modul 12A

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Nutrition Assessment Completed

Decision to initiate specialized nutrition supportDecision to initiate specialized nutrition support

Functional GI tract ?Functional GI tract ?YESYES NONO

ENTERAL NUTRITIONENTERAL NUTRITION PARENTERAL NUTRITIONPARENTERAL NUTRITION

GI-functionGI-function

Long termLong term

GastrostomyGastrostomy

JejunostomyJejunostomy

Short termShort term

NasogastricNasogastric

NasoentericNasoenteric

normalnormal compromisedcompromised

Intact nutrientsIntact nutrients Defined formulaDefined formula

Long term/ fluid Long term/ fluid restrictionrestriction

Short termShort term

Central-PNCentral-PN Peripheral-PNPeripheral-PN

GI-FUNCTION RETURN?GI-FUNCTION RETURN?

YESYES NONO

Adequate Adequate NutritionNutrition

Inadequate Nutrition

Adequate Adequate NutritionNutrition

PN-supplementation A.S.P.E.N - 1998A.S.P.E.N - 1998

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Why patients should be fed Why patients should be fed enterally rather than enterally rather than

parenterally,parenterally,• Maintenance of gut integrityMaintenance of gut integrity• Prevention of bacterial (or endotoxin) Prevention of bacterial (or endotoxin)

translocation.translocation.• Maintenance of splanchnic blood flowMaintenance of splanchnic blood flow• Maintenance of adequate immune functions of Maintenance of adequate immune functions of

the gut (GALT)the gut (GALT)• Avoidance of catheter-related sepsisAvoidance of catheter-related sepsis• Cost savingsCost savings

When the gut works, useWhen the gut works, use it, or loose itit, or loose it

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ENTERAL NUTRITIONS : ENTERAL NUTRITIONS : INDICATONSINDICATONS

• Patients unable or unwilling to Patients unable or unwilling to consume adequate nutrition to meet consume adequate nutrition to meet metabolic requirement alone or with metabolic requirement alone or with assistanceassistance

• Complement insufficent intake or Complement insufficent intake or increase demandincrease demand

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ENTERAL NUTRITION : ENTERAL NUTRITION : INDICATIONSINDICATIONS

• Requires total or partial GI tract Requires total or partial GI tract function :function :– AnorexiaAnorexia– ApoplexiaApoplexia– ComaComa– SepsisSepsis– Trauma / SurgeryTrauma / Surgery– Transition from Parenteral NutritionTransition from Parenteral Nutrition

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ENTERAL NUTRITION : ENTERAL NUTRITION : CONTRAINDICATIONSCONTRAINDICATIONS

• AbsoluteAbsolute– Complete bowel obstructionComplete bowel obstruction– Severe small bowel ileus with Severe small bowel ileus with

abdominal distentionabdominal distention– Complete inability to absorb nutrients Complete inability to absorb nutrients

through the GI tractthrough the GI tract

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ENTERAL NUTRITION : ENTERAL NUTRITION : CONTRAINDICATIONCONTRAINDICATION

• RelativeRelative– Severe postprandial painSevere postprandial pain– Short bowel syndromeShort bowel syndrome– Intractable vomitingIntractable vomiting– Severe diarrheaSevere diarrhea

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GASTRIC ACCESSGASTRIC ACCESS

• Gastric route preferredGastric route preferred– Adequate gastric motilityAdequate gastric motility– Minimum risk of aspirationMinimum risk of aspiration

• Gastric route contraindicatedGastric route contraindicated– Delayed gastric emptying Delayed gastric emptying

( gastroparesis )( gastroparesis )– High risk for aspirationHigh risk for aspiration

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GASTRIC ACCESSGASTRIC ACCESS

• Gastric route advantages:Gastric route advantages:– Normal reservoir for foodNormal reservoir for food– Easy accessEasy access– Tolerates high osmotic loadsTolerates high osmotic loads– Tolerates intermitens feedingsTolerates intermitens feedings– Gastric acid destroy contaminentsGastric acid destroy contaminents– Can be placed by nursesCan be placed by nurses

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NASOGASTRIC TUBE : NASOGASTRIC TUBE : DISADVANTAGESDISADVANTAGES

• Short term use onlyShort term use only• Higher risk for aspirationHigher risk for aspiration• Difficult to confirm positionDifficult to confirm position• Small boreSmall bore• Nasopharyngeal trauma / irritationNasopharyngeal trauma / irritation• Accidental tube displacementAccidental tube displacement

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PERCUTANEOUS ENDOSCOPIC PERCUTANEOUS ENDOSCOPIC GASTROSTOMY : ADVANTAGESGASTROSTOMY : ADVANTAGES

• The same as for surgical The same as for surgical gastrostomygastrostomy

• No surgery / less invasiveNo surgery / less invasive• Minimal sedationMinimal sedation• Direct visualizationDirect visualization• < 30 minutes to place tube< 30 minutes to place tube• Lower costLower cost

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SURGICAL GASTROSTOMYSURGICAL GASTROSTOMY

• Performed in operating roomPerformed in operating room• Indicated when peg is Indicated when peg is

contraindicated or during other contraindicated or during other surgical proceduressurgical procedures

• Requires general anesthesia and full Requires general anesthesia and full surgical teamsurgical team

• In observation during recoveryIn observation during recovery• More expensive than PEGMore expensive than PEG

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POST PYLORIC ACCESSPOST PYLORIC ACCESS

• Indication for post pyloric routeIndication for post pyloric route– Patient at risk for bronchial aspiration, Patient at risk for bronchial aspiration,

gastric refluxgastric reflux– Gastric feeding contraindicated Gastric feeding contraindicated

• Gastric motility disorders : eg gastroparesisGastric motility disorders : eg gastroparesis• Upper gi tract condition : eg carcinoma Upper gi tract condition : eg carcinoma

stricture fistulastricture fistula

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POST PYLORIC ACCESSPOST PYLORIC ACCESS• AdvantagesAdvantages

Allow earlier post Allow earlier post op feedingop feeding

Lower risk of Lower risk of aspirationaspiration

DisadvantagesDisadvantages• Small bore tubes Small bore tubes

prone to obstructionsprone to obstructions• Tubes can be dislodge Tubes can be dislodge

into stomachinto stomach• Difficult to maintain Difficult to maintain

long termlong term• Potential for dumping Potential for dumping

syndromesyndrome• Requres infusion pumpRequres infusion pump

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Nasoenteric routeNasoenteric route

– Nasogastric, Nasoduodenal, NasojejunalNasogastric, Nasoduodenal, Nasojejunal– 2 - <4 weeks2 - <4 weeks– small diameter[6-12 Fr/Ch]small diameter[6-12 Fr/Ch]– Silicone, polyurethane [PUR], radioopaqueSilicone, polyurethane [PUR], radioopaque– stomach 90 cm, duodenum 110 cm, jejunum stomach 90 cm, duodenum 110 cm, jejunum

120 cm120 cm– prokinetic prokinetic R/R/ metoclopropamide, metoclopropamide,

erythromycine, cisaprideerythromycine, cisapride– inner styletsinner stylets– proper placement in stomach proper placement in stomach pH specimen pH specimen

aspirated <5.0aspirated <5.0

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Nasoenteric Feeding Tube Nasoenteric Feeding Tube CompositionComposition

PVCPVC SiliconeSilicone PURPUR

Ease to Ease to insertioninsertion

To stiff for To stiff for comfortcomfort

To softTo soft AdequateAdequate

Ability to Ability to aspirate gastric aspirate gastric contentcontent

ExcellentExcellent Poor to fairPoor to fair GoodGood

Patient comfortPatient comfort Very poorVery poor ExcellentExcellent GoodGood

Durability/Durability/strengthstrength

Strong but Strong but brittlebrittle

Breaks easilyBreaks easily Excellent/Excellent/strongstrong

Peggi Guenter: Delivery System Administration of Enteral Nutrition, in Rombeau JL, Clinical Nutrition, Enteral and Tube

Feeding,1997:244.

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Naso Gastric TubeNaso Gastric Tube

(NGT)(NGT)

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Percutaneous routePercutaneous route

• PEG, PEJ, combined nasogastric PEG, PEJ, combined nasogastric jejunaljejunal

• PEG, procedure of choice for ICU PEG, procedure of choice for ICU patients. [ ≥ 4-6 weeks]patients. [ ≥ 4-6 weeks]

• 9-24Fr 9-24Fr • Relative CI, ascites, gastric cancer, Relative CI, ascites, gastric cancer,

gastric ulcer, previous laparotomy, gastric ulcer, previous laparotomy, coagulation disorder.coagulation disorder.

• Post-pyloric feeding Post-pyloric feeding PEJ. PEJ.

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PEGPEG

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DURANTE OPERATIONEMDURANTE OPERATIONEM

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Choosing the Feeding SiteChoosing the Feeding SiteCan the GI tract be used ?

Parenteral Nutrition Tube feeding for more 2-4 weeks ?

Nasoenteric Tube Enterostomy Tube

Risk for pulmonary aspiration ?

NGT Nasoduodenal or nasojejunal tube

Gastrostomy Jejunostomy

No Yes

No Yes

No Yes YesNo

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TIMINGTIMING

• Early feedingEarly feeding refers to beginning refers to beginning nutrition within nutrition within the first 24-48 the first 24-48

hrshrs after an acute event after an acute event

(Should be initiated within (Should be initiated within 18 18 hours of injury in burn patienthours of injury in burn patient

EARLYEARLY

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Enteral Formulas : Enteral Formulas : CategoriesCategories

• Polymeric formulasPolymeric formulas– CommercialCommercial– BlenderizedBlenderized

• Oligomeric formulasOligomeric formulas• Disease-specific formulasDisease-specific formulas• Modular (concentrated protein and Modular (concentrated protein and

carbohydrate preparations)carbohydrate preparations)

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Benefits of Commercial Benefits of Commercial FormulasFormulas

Commercial FormulasCommercial Formulas

• Uniform contentsUniform contents• SterileSterile• Low viscosityLow viscosity• Lactose freeLactose free• Defined caloric Defined caloric

densitydensity

Blenderized FormulasBlenderized Formulas

• Daily nutrient variabilityDaily nutrient variability• Non sterileNon sterile• High viscosityHigh viscosity• Does not provide Does not provide

adequate caloric densityadequate caloric density

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Polymeric FormulasPolymeric Formulas

Contain intact macronutrients and require Contain intact macronutrients and require digestiondigestion

• Intact proteinIntact protein• PolysaccharidesPolysaccharides• DisaccharidesDisaccharides

• PUFAPUFA• MCTMCT

• Vitamine and MineralVitamine and Mineral• R/ Entrasol, PeptisolR/ Entrasol, Peptisol

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Commercial Polymeric Formulas Commercial Polymeric Formulas ::

SelectionSelection• FeaturesFeatures

– Protein, caloric density and osmolality varyProtein, caloric density and osmolality vary– With or without added fiberWith or without added fiber– Most are gluten and lactose freeMost are gluten and lactose free– Nutritionally complete in sfficient quantitiesNutritionally complete in sfficient quantities

• Patient must havePatient must have– Functional GI tractFunctional GI tract– Normal digestionNormal digestion– Normal absorptionNormal absorption

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Oligomeric Formula CategoriesOligomeric Formula Categories((elemental, semi-elemental, hydrolyzed, elemental, semi-elemental, hydrolyzed,

chemically defined)chemically defined)• Hydrolized macronutrientsHydrolized macronutrients facilitate digestion and absorptionfacilitate digestion and absorption

• Amino acids

• Glutamine

• Arginine

• Peptides

• Monosaccharides

• Disaccharides

• Glucose polymers

• PUFA

• MCT

• Vitamins and Minerals

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Oligomeric Formulas :Oligomeric Formulas :SelectionSelection

Indication for UseIndication for Use– Inflammatory bowel disease Pancreatic Inflammatory bowel disease Pancreatic

insufficiencyinsufficiency– MalabsorptionMalabsorption– Short Bowel syndromeShort Bowel syndrome– Radiation enteritisRadiation enteritis– early enteral feedingearly enteral feeding– Intolerance to polymeric formulaIntolerance to polymeric formula

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Disease-Specific FormulasDisease-Specific Formulas• Pulmonary diseasePulmonary disease• Glucose intoleranceGlucose intolerance• Cancer induced weight lossCancer induced weight loss• Hepatic insufficiencyHepatic insufficiency• Critical CareCritical Care• Renal failureRenal failure• HIV-AIDSHIV-AIDS

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Pulmonary disease Pulmonary disease (Chronic)(Chronic)

• Decreased CHO contentDecreased CHO content• Increased fat contentIncreased fat content• High Caloric densityHigh Caloric density• Intact proteinsIntact proteins• Fiber supplementFiber supplement• antioxidantantioxidant

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Glucose Glucose IntoleranceIntolerance

• Low CHO contentLow CHO content– Monosaccharides (fructose)Monosaccharides (fructose)– Glucose polymerGlucose polymer

• MUFAMUFA• Added fiberAdded fiber• R/ DiabetasolR/ Diabetasol

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Cancer induced weight lossCancer induced weight loss

• High protein and Zn to build muscleHigh protein and Zn to build muscle• Low fat to early satietyLow fat to early satiety• Low in sucrose for better patient Low in sucrose for better patient

acceptanceacceptance• High in fermentable fibersHigh in fermentable fibers• Eicosapentaenoic acid (EPA)Eicosapentaenoic acid (EPA)• Antioxidants (vit-A, C, E and Se)Antioxidants (vit-A, C, E and Se)• Folate and Iron for anemiaFolate and Iron for anemia

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Hepatic DiseaseHepatic Disease• High caloric density with low sodium contentHigh caloric density with low sodium content• Moderately high calorie nitrogen ratioModerately high calorie nitrogen ratio• High in BCAA, low in AAAHigh in BCAA, low in AAA• Non digestible soluble fiberNon digestible soluble fiber• Long chain FA, supplemental MCTLong chain FA, supplemental MCT• Fat soluble vitamins, Zn, folic acid and B-Fat soluble vitamins, Zn, folic acid and B-

complex complex • Low Cu, Fe and PhosphatLow Cu, Fe and Phosphat• R/ HepatosolR/ Hepatosol

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Critical CareCritical Care (Mechanical Ventilation)(Mechanical Ventilation)

• Lung injury, SIRS, ARDSLung injury, SIRS, ARDS– EPAEPA– GLAGLA– AntioxidantAntioxidant– High caloric densityHigh caloric density– No Arginine supplementationNo Arginine supplementation

““Giving Arginine to septic patient is like putting Giving Arginine to septic patient is like putting gasoline on an already burning fire’’gasoline on an already burning fire’’

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ENTERAL FORMULA : ENTERAL FORMULA : ORAL ADMINISTRATIONORAL ADMINISTRATION

• Oral supplementationOral supplementation– Indicated especially for patients with Indicated especially for patients with

malnutrition or at risk for weight lossmalnutrition or at risk for weight loss– When given between meals, does not When given between meals, does not

reduce intake of other foodsreduce intake of other foods– Frequently stimulates increased intake Frequently stimulates increased intake

of other foodsof other foods– Thickened oral supplements are useful Thickened oral supplements are useful

for patients with dysphagiafor patients with dysphagia

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ENTERAL FORMULA : ENTERAL FORMULA : TUBE FEEDINGTUBE FEEDING

• TypeType– IntermittentIntermittent– Continous :Continous :

• 24 hours / day24 hours / day• During part of the day or at nightDuring part of the day or at night

• Infusion methodInfusion method– GravityGravity– Infusion pumpInfusion pump

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ENTERAL FORMULA : ENTERAL FORMULA : ADMINISTRATIONADMINISTRATION

• Enteral feedingEnteral feeding– Intermittent:Intermittent:

• Resembles normal feeding and digestion Resembles normal feeding and digestion patterspatters

• 250 – 500 ml of formula250 – 500 ml of formula• Administered over 30 – 60 minutesAdministered over 30 – 60 minutes• 5 – 8 times daily5 – 8 times daily

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ENTERAL FORMULA : ENTERAL FORMULA : ADMINISTRATIONADMINISTRATION

• ContinuousContinuous– Plan Plan II

• Beginning day one : 1000cc over 24 hoursBeginning day one : 1000cc over 24 hours• Progress day two : 1500 cc over 24 hourProgress day two : 1500 cc over 24 hour

day three: final vol day three: final vol according to needsaccording to needs

– Plan Plan IIII• Beginning 25 cc / h ( first 12 hours )Beginning 25 cc / h ( first 12 hours )• Progress 50 cc / h for next 12 hoursProgress 50 cc / h for next 12 hours

rate according to needrate according to need

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ENTERAL FORMULA : ENTERAL FORMULA : ADMINISTRATIONADMINISTRATION

• Infusion pump indicationsInfusion pump indications– Small intestine feedingSmall intestine feeding– Fluid restrictionFluid restriction– Risk of aspirationRisk of aspiration– Need for precise flow rateNeed for precise flow rate– Nocturnal feedingNocturnal feeding– Infants and small childrenInfants and small children

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• Gravity infusion indicationGravity infusion indication– Suitable for intermittent feedingSuitable for intermittent feeding– Ambulatory patientsAmbulatory patients– Gastric feeding Gastric feeding

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ENTERAL FORMULA : ENTERAL FORMULA : ADMINISTRATIONADMINISTRATION

• SummarySummary– Intermittent feedingIntermittent feeding– Continous feedingContinous feeding

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• Intermittent (bolus)Intermittent (bolus)

Administering tube Administering tube feedingfeeding

• naso gastric tube, gastrostomynaso gastric tube, gastrostomy

• head up position 30head up position 3000

• start gastric feeding of 150-200ml over 20-40 start gastric feeding of 150-200ml over 20-40 minutes, minutes,

• increase by 50-100ml each feeding as tolerated to increase by 50-100ml each feeding as tolerated to goalgoal

• followed by 30 ml warm water flushfollowed by 30 ml warm water flush

• check residuals before next feeding (up to half)check residuals before next feeding (up to half)

• for sign of intolerance (diarrhea, vomiting), reduce for sign of intolerance (diarrhea, vomiting), reduce to last tolerated step, evaluate clinically.to last tolerated step, evaluate clinically.

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Continuous (drip infusion)Continuous (drip infusion) Intragastric, duodenal, jejunalIntragastric, duodenal, jejunalStart at 30-50 ml/hr isotonic formulaStart at 30-50 ml/hr isotonic formula Increase by 30-50/hr every 6-8 hours to goalIncrease by 30-50/hr every 6-8 hours to goalMaximum 100-150ml/hrMaximum 100-150ml/hrMost tube fedings are tolerated at full strengthMost tube fedings are tolerated at full strengthReduce risk ( retention, aspiration)Reduce risk ( retention, aspiration) followed by 30 ml warm water flushfollowed by 30 ml warm water flush for sign of intolerance (diarrhea, vomiting), for sign of intolerance (diarrhea, vomiting),

reduce to last tolerated step, evaluate reduce to last tolerated step, evaluate clinically.clinically.

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Continuous drip infusion

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MonitoringMonitoring,,• Metabolic, gastrointestinal, mechanical Metabolic, gastrointestinal, mechanical

assessmentassessment• Routine dayli evaluation of intake,output, weightRoutine dayli evaluation of intake,output, weight• Acutely ill patients require daily to weekly serum Acutely ill patients require daily to weekly serum

electrolyte, glucose, BUN, Cr, Ca++, Mg++, Ph.electrolyte, glucose, BUN, Cr, Ca++, Mg++, Ph.• Stable patients require weekly-monthly Stable patients require weekly-monthly

laboratory studieslaboratory studies• Elevate head of bed 30Elevate head of bed 3000 during feeding during feeding• Check stomach for high residuals to minimize Check stomach for high residuals to minimize

aspiration riskaspiration risk

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• Metabolic : overhydration, dehydration, Metabolic : overhydration, dehydration, undernutrition, hyperglycemia,undernutrition, hyperglycemia, electrolyte imbalanceelectrolyte imbalance• Gastrointestinal : nausea, vomiting, constipationGastrointestinal : nausea, vomiting, constipation abd. discomfort, diarrheaabd. discomfort, diarrhea• Mechanical : misplaced, Mechanical : misplaced, clogged feeding tubeclogged feeding tube airway, GI tract injury with NG/NJ airway, GI tract injury with NG/NJ tube placement.tube placement.• Infectious : peritonitis, exit site infection, sinusitis,Infectious : peritonitis, exit site infection, sinusitis, aspiration pneumoniaaspiration pneumonia

ComplicationsComplications

Terima kasih atas perhatian andaSemoga Tuhan selalu memberkahi kita semua

Amin

Nutrisi Enteral Skill Nutrisi Enteral Skill

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