Enteral and

Parenteral
Nutrition Support
2004, 2002 Elsevier Inc. All rights reserved.
Enteral Nutrition Definition

Nutritional support via placement through
the nose, esophagus, stomach, or intestines
(duodenum or jejunum)
Tube feedings
Must have functioning GI tract
IF THE GUT WORKS, USE IT!
Exhaust all oral diet methods first.
2004, 2002 Elsevier Inc. All rights reserved.
Conditions That Require Other
Nutrition Support
Enteral
Impaired ingestion
Inability to consume adequate nutrition
orally
Impaired digestion, absorption, metabolism
Severe wasting or depressed growth
Parenteral
Gastrointestinal incompetency
Hypermetabolic state with poor enteral
tolerance or accessibility

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Considerations in Enteral Nutrition
1. Applicable
2. Site placement
3. Formula selection
4. Nutritional/medical requirements
5. Rate and method of delivery
6. Tolerance
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Formula Selection
The suitability of a feeding formula should be
evaluated based on

Functional status of GI tract
Physical characteristics of formula (osmolality,
fiber content, caloric density, viscosity)
Macronutrient ratios
Digestion and absorption capability of patient
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte
needs or restriction
Cost effectiveness
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Enteral Formula Categories
Intact formula
Hydrolyzed formula
Rehydration
Modular


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Enteral Access: Clinical Considerations
Duration of tube feeding
Nasogastric or nasoenteric tube for short term
Gastrostomy and jejunostomy tubes for
long term
Placement of tube
Gastric
Small bowel
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Placement Site
Access (medical status)
Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning
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Enteral Tube Placement
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AdvantagesEnteral Nutrition
Intake easily/accurately monitored
Provides nutrition when oral is not
possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with
disease state
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More Advantages
Enteral Nutrition
Preserves gut integrity
Decreases likelihood of bacterial
translocation
Preserves immunologic function of gut
Increased compliance with intake


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DisadvantagesEnteral Nutrition
GI, metabolic, and mechanical
complicationstube migration; increased
risk of bacterial contamination; tube
obstruction; pneumothorax
Costs more than oral diets
Less palatable/normal
Labor-intensive assessment, administration,
tube patency and site care, monitoring
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Complications of Enteral Feeding
Access problems (tube obstruction)
Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)
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Aspiration Pneumonia
Can result from enteral feeds
High-risk patients
Poor gag reflex
Depressed mental status
Elevate head of the bed >30 degrees during
feedings

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Rate and Method of Delivery*
Bolus300 to 400 ml rapid delivery via syringe
several times daily
Intermittent300 to 400 ml, 20 to 30 minutes,
several times/day via gravity drip or syringe
Cyclicvia pump usually at night
Continuousvia gravity drip or infusion pump

*Determined by medical status, feeding route and
volume, and nutritional goals
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Administration: Feeding Rate
Continuous method = slow rate of 50 to 150
ml/hr for 12 to 24 hours
Intermittent method = 250 to 400 ml of
feeding given in 5 to 8 feedings per 24 hours
Bolus method = may give 300 to 400 ml
several time a day (push is not desired)
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Routes of Parenteral Nutrition
Central access
TPN both long- and short-term placement
Peripheral or PPN
New catheters allow longer support via
this method limited to 800 to 900 mOsm/kg
due to thrombophlebitis
<2000 kcal required or <10 days
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Venous Sites from Which the Superior Vena Cava
May Be Accessed
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AdvantagesParenteral Nutrition
Provides nutrients when less than
2 to 3 feet of small intestine remains
Allows nutrition support when GI
intolerance prevents oral or enteral
support
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Indications for Total
Parenteral Nutrition
GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food
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Contraindications
GI tract works
Terminally ill
Only needed briefly (<14 days)
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Administration
Start slowly
(1 L 1st day; 2 L 2nd day)
Stop slowly
(reduce rate by half every 1 to 2 hrs
or switch to dextrose IV)
Cyclic give 12 to 18 hours per day
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Monitoring and Complications
Infection
Hemodynamic stability
Catheter care
Refeeding syndrome
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Refeeding Syndrome
Hypophosphatemia
Hyperglycemia
Fluid retention
Cardiac arrest
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Problems
PPN
Site irritation
TPN
1. Catheter sepsis
2. Placement problems
3. Metabolic