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enteral nutrition

Daily parenteral requirements: Nutrient Quantity essential fatty acids 1-2% of total calories calcium 0.8-1.2 g phosphorous 0.8.1.2 g potassium 2-5 g sodium 1-3 g chloride 2-5 g magnesium 0.3 g iron 10 mg zinc 15 mg copper 2-3 mg iodine 0.15 mg manganese 2-5 mg chromium 50-200 ug molybdenum 150-300 ug selenium 50-200 ug ascorbate 60 mg thiamine 1.4 mg riboflavin 1.6 mg niacin 18 mg biotin 60 ug pantothenate 5 mg pyridoxine 2.0 mg folate 400 ug cobalamin 3.0 ug vitamin A 1000 ug vitamin D 10 ug vitamin E 8-10 mg vitamin K 70-140 ug Enteral feeding tubes: 1) nasogastric tube 2) nasojejunal tube 3) gastrostomy tube 4) jejunostomy tube 5) combined gastrojejunostomy tube (G/J tube) Indications: - unable to eat, but GI tract intact - critical illness, especially with high metabolic demand - burns - enteral feeding maintains integrity of GI tract - prevents disuse atropy * if the gut works, use it Contraindications: - gastrointestinal injury - see indications for parenteral nutrition - enteral feeding does not prolong life in patients with advanced dementia [4] Complications: 1) diarrhea*, constipation 2) abdominal distension 3) pulmonary aspiration 4) early refeeding syndrome in malnourished patients [3] * when diarrhea from malabsorption leads to diminished calorie intake, diminished calorie intake is the said cause of weight loss [9] Management: - elevate the head when supine - start within 24-48 hour of admission [3] - in malnourished patients, gradually increase feedings over 3-7 days to goal [3] - do not check gastric residuals - of little or no value in preventing ventilator-associated pneumonia in patients on enteral feeding [2,3] - may increase risk of aspiration pneumonia - may clog enteral access - no benefit of high-protein enteral feeds enriched with antioxidants, glutamine, & omega-3 fatty acids [5] - most patients with critical illness, including those with burns & airway injury can tolerate placement of an enteral feeding tube (nasogastric tube) [3] - permissive underfeeding associated with similar outcomes as standard enteral feeding [6] - routine use of energy dense feeds confers no benefit [7] - parenteral nutrition should not be added to enteral feeding [3]

Related

enteral enteral formula feeding gastrostomy feeding tube jejunostomy nasogastric tube (NGT) placement (gastric intubation) nasojejunal tube

General

nutritional therapy

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 477
  2. Reignier J et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: A randomized controlled trial. JAMA 2013 Jan 16; 309:249 PMID: 23321763 - Rice TW. Gastric residual volume: End of an era. JAMA 2013 Jan 16; 309:283. PMID: 23321767
  3. Medical Knowledge Self Assessment Program (MKSAP) 16, 18, 19 American College of Physicians, Philadelphia 2012, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - Martindale RG, McClave SA, Vanek VW et al Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: Executive Summary. Crit Care Med. 2009 May;37(5):1757-61 PMID: 19373044
  4. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209. Review. PMID: 19370678
  5. van Zanten ARH et al. High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: A randomized clinical trial. JAMA 2014 Aug 6; 312:514 PMID: 25096691
  6. Arabi YM et al. Permissive underfeeding or standard enteral feeding in critically ill adults. N Engl J Med 2015 Jun 18; 372:2398 PMID: 25992505
  7. TARGET Investigators, for the ANZICS Clinical Trials Group. Energy-dense versus routine enteral nutrition in the critically ill. N Engl J Med 2018 Oct 22 PMID: 30346225 Free Article https://www.nejm.org/doi/10.1056/NEJMoa1811687
  8. Taylor BE, McClave SA, Martindale RG et al Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016 Feb;44(2):390-438. PMID: 26771786
  9. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  10. NEJM Knowledge+ Gastroenterology