PRESCRIBING REGIMENS OF FEEDING JEJUNOSTOMY

RUPESH KUMAR PGT,DEPT OF SURGERY MEDICAL COLLEGE, KOLKATA

Definition
Enteral nutrition: the provision of nutrients

into the gastrointestinal tract through a tube or catheter when oral intake is inadequate. Also it may include the use of formula as oral supplements or meal replacement.

Principles of Enteral Feeding

Stomach Principal defense against an

enteral osmotic load.

SI - Principal area for nutrient absorption. Hyperosmolar solutions invites more

complications.

Routes for administration of enteral feeding

Nasoenteric and postpyloric feeding. Gastrostomy Jejunostomy

An approach to feeding advancement

Position of the patient For gastric feeding- first osmolality then

volume is increased. Feeding started at the @ 10-20mL/hr Gastric volumes checked every 4-6 hrs If less <100-150mL Feeding advanced in 10-20mL increments until the goal is attained.

For SI feeding- volume is increased first then the osmolality ( <300-400mOsm ) Opioids to slow diarrhea

Rationale for enteral nutrition

Low cost intestinal mucosal atrophy. infection complications & acute phase

protein production

Which patient is eligible for nutrition support ?

Enteral nutrition Should be used in Pt. who have at least 2-3 ft of functional gastrointestinal tract. Who are or will become malnourished. In whom oral intake is inadequate to restore or maintain optimal nutritional status.

General Indications:

The pts premorbid state Poor nutritional status Significant weight loss Duration of starvation > 7 days Anticipated duration of artificial nutrition >7days The degree of anticipated insult, surgical/ otherwise Serum albumin< 3gm%,transferrin<200mg% Anergy to injected antigens

Where there is a functional GI

ENTERAL FORMULA COMPOSITION

Formulas classified in a variety of ways, usually based on protein or overall macronutrients composition.
General purpose formulas are tolerated by most

patients and most of these formulas provide 1 kcal / ml.

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General formulas that provide 1.5 to 2 kcal / ml

are used to restrict fluid for patients with cardiopulmonary, renal & hepatic failure.
High nitrogen formulas used for patients with

burns, fistulas, sepsis or trauma.

Disease specific formulas for patients with

renal, hepatic or cardiopulmonary disease, metabolic stress,immunosuppression, or glucose intolerance.

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ENTERAL FORMULA CATEGORIES

General purpose / intact (polymeric)
* Use in patients with normal digestion and absorption. * Contain intact protein. * Instituted at full strength ; low viscosity; 300-500 mOsm / kg. * Provide 1-2 kcal / ml. * Lactose free. * 30-40 gm protein / L. Use in patients with GI compromise. (hydrolyzed nutrients to improve digestion). Osmolality depends on hydrolysis. Provide 1-2 kcal / ml. Lactose free. 30-45 gm protein / L. Also known as chemically defined, peptide based and elemental formula. use in patients with limited GI function. contains free amino acids, minimal fat and minimal residue. hyperosmolar and low viscosity. provide 1 kcal / ml. 40 gm protein / L. Also known as free amino acid formula.
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Defined / hydrolyzed (monomeric)

Semielemental

ENTERAL FORMULA CATEGORIES (CONT.)

Disease specific
Designed for specific organ dysfunction or metabolic disorder. May not nutritionally complete. Most are hyperosmolar.

Redehydration

For patient requiring an optimal ratio of simple carbohydrate to electrolytes for the purpose of maximizing fluid and electrolyte absorption and rehydration. Formula providing protein, fat or carbohydrate as single nutrients to alter the nutrient composition of commercial formulas or food.

Modular

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ADMINISTRATION
The three common methods of tube feeding administration are : 1. Bolus feeding: infusion of up to 5oo ml of enteral formula over 5 to 20 mins by large-bore syringe . 2. Intermittent drip feeding: administered of enteral feeding at specified times throughout the day; generally in smaller volume and at a slower rate than a bolus feeding but in large volume and faster rate than continuous feeding.
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3. Continuous drip feeding: administered of enteral formula into the gastrointestinal tract via pump, usually over 8 to 24 hours of day.

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Products
Complete Formulas Modular (Supplements) Elemental Disease Specific

Complete formulas
Also called meal replacements Intact nutrients One or two sources of protein, carbohydrate and fat Carbohydrate: Maltodextan, hydrolyzed corn starch, corn syrup Protein: Soy protein, casein Fat: Soybean oil, canola oil, corn oil Vitamins: RDA in 1250 2000 ml Minerals: Na, K, MG, Phos, Ca & usually trace With and without fiber

Modular products
Also called supplements Provides only one type of nutrient Given with a complete formula
Protein: ProMod, Propac Fat: MCT oil, Safflower oil Carbohydrate: Polycose, corn syrup

Elemental formulas
Nutrients broken down Low fat MCT oil Examples: Peptamin; Criticare HN Use: Malabsoption states: Short bowel,

fistula, pancreatitis

Disease specific formulas

Hepatic disease Renal disease Trauma & stress Pulmonary disease Diabetes

Hepatic disease
Low in aromatic amino acids and methionine High in branched chained amino acids Low in amino acid concentration (High calorie to nitrogen ratio) Products: Hepatic-Aid II

Renal disease
Amin-Aid; Suplena Low protein, high in essential AA Modified electrolytes Caloric dense Nepro higher in protein for dialysis patients

Trauma & stress

TraumaCal; Stresstein; AlitraQ High nitrogen May be high in BCAA Caloric dense

Pulmonary disease
Pulmocare 55% of calories from fat Primarily corn oil Intended to decrease CO2 production

Diabetes
Glucerna
Less carbohydrate More fat

Intended to improve glucose tolerance

Monitoring pts receiving nutritional support

Fluid balance record, daily weighing Document daily calorie and N intake

RFT, LFT biweekly

Regular check ups for Phos,Ca,Mg,alb,Protein,

Haematological indices Regular examination of route of access

Complications of enteral nutrition

Gastrointestinal Diarrhea, nausea,

vomiting, abd discomfort, bloating, regurgitation and aspiration of fluids. Mechanical Metabolic Infective-

Thank You